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1 Artesunate (4mg/kg
. BB/hari)
3 hari
Amodiaquin (10 mg/kg
Primakuin 1 hari
First Line BB/hari)
(0,75 (Hari
(ACT) 2 Dihydroartemisinin (2-4
mg/kg BB) pertama)
. mg/kg BB/hari)
3 hari
Piperakuin (16-32 mg/kg
BB/hari)
1 3x
Kina (10 mg/kg BB/kali)
. 1
Doksisiklin (dewasa: 7
2x
4mg/kg BB; usia 8-14: 2 hari
1 Primakuin 1 hari
Second mg/kg BB/kali)
(0,75 (Hari
Line
2 3x mg/kg BB) pertama)
Kina (10 mg/kg BB/kali)
1 7
Tetrasiklin (4-5 mg/kg
4x hari
BB/kali)
1
Keterangan:
First Line:
- ACT tidak dapat diberikan pada ibu hamil trimester 1
- Primakuin tidak dapat diberikan pada Ibu hamil, bayi usia <6 bulan, penderita defisiensi
G6DP, ibu menyusui (usia bayi<6 bulan)
Second Line :
- Diberikan jika pengobatan first line tidak efektif dimana ditemukan: gejala klinis tidak
memburuk tapi parasit aseksual tidak berkurang (persisten) atau timbul kembali
(rekrudensi)
- Doksisiklin dan Tetrasiklin tidak dapat diberikan pada ibu hamil dan anak usia<8tahun
Obat sebaiknya diberikan sesuai berat badan, karena jika tidak sesuai akan menimbulkan efek
samping yang lebih berat karena dosis tidak tepat (berlebih) seperti mual muntah sakit kepala
Apabila pemberian dosis tidak memungkinkan sesuai berat badan penderita, pemberian obat
dapat diberikan berdasarkan golongan umur (Tabel IV.1-4)
Sediaan dosis dalam tablet
Artesunat : 200 gr (setara dengan
150gr basa)
Amodiakuin : 50 gr
Primakuin : 25 gr (setara dengan 15gr
basa)
Doksisiklin
Sediaan dosis dalam tablet atau
kapsul
50 dan 100 mg
Tetrasiklin
Sediaan dosis dalam bentuk kapsul
250 dan 500 mg
1 Artesunate (4mg/kg
. BB/hari)
3 hari
Amodiaquin (10 mg/kg
Primakuin
First Line BB/hari)
(0,25 14 hari
(ACT) 2 Dihydroartemisinin (2-4
mg/kg BB)
. mg/kg BB/hari)
3 hari
Piperakuin (16-32 mg/kg
BB/hari)
Second 1 Kina (10 mg/kg BB/kali) 3x 7 Primakuin 14 hari
Line . 1 hari (0,25 mg/kg
BB)
Keterangan:
Second Line :
- Diberikan jika pengobatan first line tidak efektif dimana ditemukan: gejala klinis tidak
memburuk tapi parasit aseksual tidak berkurang (persisten) atau timbul kembali
(rekrudensi)
- Doksisiklin dan Tetrasiklin tidak dapat diberikan pada ibu hamil dan anak usia<8tahun
Pengobatan cukup dengan ACT 1 kali per-hari selama 3 hari dengan dosis yang sama
seperti pengobatan untuk malaria yang lainnya
CHLOROQUINE
Chloroquine has been the drug of choice for both treatment and chemoprophylaxis of malaria since the 1940s, but its
usefulness against P falciparum has been seriously compromised by drug resistance.
Chloroquine probably acts by concentrating in parasite food vacuoles, preventing the biocrystallization of the
hemoglobin breakdown product, heme, into hemozoin, and thus eliciting parasite toxicity due to the buildup of free
heme. It rapidly terminates fever (in 2448 hours) and clears parasitemia (in 4872 hours) caused by sensitive
parasites.
Adverse Effects
Chloroquine is usually very well tolerated, even with prolonged use. Dosing after meals may reduce some adverse
effects. Rare reactions include hemolysis in glucose-6-phosphate dehydrogenase (G6PD)-deficient persons, impaired
hearing, confusion, psychosis, seizures, agranulocytosis, exfoliative dermatitis, alopecia, bleaching of hair,
hypotension.
OTHER QUINOLINES
Amodiaquine
Shares mechanisms of action and resistance with that drug. Amodiaquine has been widely used to treat malaria because
of its low cost, limited toxicity, and, in some areas, effectiveness against chloroquine-resistant strains of P falciparum
thus it may be used as a replacement for chloroquine in areas with high rates of resistance but limited resources.
The World Health Organization (WHO) lists amodiaquine plus artesunate as a recommended therapy for falciparum
malaria in areas with resistance to older drugs. This combination is now available as a single tablet (ASAQ, Arsucam,
Coarsucam)
Chemoprophylaxis with amodiaquine is best avoided because of its apparent increased toxicity with
long-term use.
Piperaquine
is a bisquinoline that has been combined with
dihydroartemisinin in co-formulated tablets (Artekin,
Duocotecxin) that have shown excellent efficacy and safety for the treatment of falciparum malaria, without apparent
drug resistance. Piperaquine has a longer half-life ( 28 days) than amodiaquine ( 14 days), mefloquine ( 14 days),
or lumefantrine ( 4 days), leading to a longer period of post-treatment prophylaxis with dihydroartemisinin-
piperaquine than with the
other leading artemisinin-based combinations; this feature should be particularly advantageous in high transmission
areas.
The WHO recommends five artemisinin-based combinations for the treatment of uncomplicated falciparum malaria
Adverse Effects & Cautions
Artemisinins are generally very well tolerated. The most commonly reported adverse effects are nausea, vomiting,
diarrhea, and dizziness, and these may often be due to underlying malaria rather than the medications. Rare serious
toxicities include neutropenia, anemia, hemolysis, elevated liver enzymes, and allergic reactions.
Artemisinins have been embryotoxic in animal studies, but rates of congenital abnormalities, stillbirths, and abortions
were not elevated, compared with those of controls, in women who received artemisinins during pregnancy. Based on
this information and the significant risk of malaria during pregnancy, the WHO recommends artemisininbased
combination therapies for the treatment of uncomplicated falciparum malaria during the second and third trimesters of
pregnancy, intravenous artesunate or quinine for the treatment of severe malaria during the first trimester, and
intravenous artesunate for treatment of severe malaria during the second and third trimesters.
PRIMAQUINE
Primaquine is the drug of choice for the eradication of dormant liver forms of P vivax and P ovale and can also be used
for chemoprophylaxis against all malarial species.
Adverse Effects
Primaquine in recommended doses is generally well tolerated. It infrequently causes nausea, epigastric pain, abdominal
cramps, and headache, and these symptoms are more common with higher dosages and when the drug is taken on an
empty stomach.
Standard doses of primaquine may cause hemolysis or methemoglobinemia (manifested by cyanosis), especially in
persons with G6PD deficiency or other
hereditary metabolic defects.
COMPLICATION OF MALARIA
Cerebral Malaria
Coma is a characteristic and ominous feature of falciparum malaria and, despite treatment, is
associated with death rates of ~20% among adults and 15% among children. Th onset may be
gradual or sudden following a convulsion. Cerebral malaria manifests as diffuse symmetric
encephalopathy.
Hypoglycemia
Hypoglycemia, an important and common complication of severe malaria, is associated with a
poor prognosis and is particularly problematic in children and pregnant women. Hypoglycemia
in malaria results from a failure of hepatic gluconeogenesis and an increase in the
consumption of glucose by both the host and, to a much lesser extent, the malaria parasites.
To compound the situation, quinine, which is still widely used for the treatment of both severe
and uncomplicated falciparum malaria, is a powerful stimulant of pancreatic insulin secretion.
Hyperinsulinemic hypoglycemia is especially troublesome in pregnant women receiving
quinine treatment.
Acidosis
Acidosis, an important cause of death from severe malaria, results from accumulation of
organic acids. Hyperlactatemia commonly coexists with hypoglycemia. Acidotic breathing,
sometimes called respiratory distress, is a sign of poor prognosis.
Hematologic Abnormalities
Anemia results from accelerated RBC removal by the spleen, obligatory RBC destruction at
parasite schizogony, and ineffective erythropoiesis. In severe malaria, both infected and
uninfected RBCs show reduced deformability, which correlates with prognosis and
development of anemia. Splenic clearance of all RBCs is increased. Anemia is a common
consequence of antimalarial drug resistance, which results in repeated or continued infection.
Slight coagulation abnormalities are common in falciparum malaria, and mild
thrombocytopenia is usual
Liver Dysfunction
Mild hemolytic jaundice is common in malaria. Severe jaundice is associated with P. falciparum
infections; is more common among adults than among children; and results from hemolysis,
hepatocyte injury, and cholestasis. Hepatic dysfunction contributes to hypoglycemia,
lactic acidosis, and impaired drug metabolism.