We prospectively studied 803 Thai patients admitted to the Bangkok Hospital for Tropical Diseases to assess the safety, tolerability and effectiveness of treatments for strictly defined P.
falciparum malaria. Patients were assigned to one of five treatment groups: (i) a 5-day course of intravenous
artesunate in a total dose of 600 mg, Group Aiv; (ii) intravenous
artesunate as in Group Aiv followed by
mefloquine, 25 mg/kg, Group Aiv+M; (iii) a 3-day course of intramuscular
artemether in a total dose of 480 mg, Group Aim; (iv) intramuscular
artemether as in Group Aim followed by
mefloquine, 25 mg/kg, Group Aim+M, and (v) intravenous
quinine, 200 mg/kg given in divided doses over seven days followed by oral tetracylcine, 10 mg/kg, for 7 days. When patients could take oral medications, the parenteral
antimalarials were administered as oral agents. There were no major adverse effects observed with any of the five treatment regimens. With all regimens, 95 to 100% of the patients survived. Mean parasite clearance times were more rapid with the
artemisinin regimens (53 to 62 hours) than with
quinine (92 hours). The mean
fever clearance times with intravenous
artesunate (80 to 82 hours) were about a day shorter than those with intramuscular
artemether (108 hours) or intravenous
quinine (107 hours).
Mefloquine reduced the recrudescence rate from 24 to 5% with intravenous
artesunate but from 45 to 20% with intramuscular
artemether; recrudescence was 4% with
quinine and
tetracycline. A dose and
duration of therapy greater than those in this study are needed for optimal
therapy with intramuscular
artemether. Effective
therapy for severe
falciparum malaria can be provided by either intravenous
artesunate followed by
mefloquine or by intravenous
quinine followed by
tetracycline.