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Abstract
In the treatment of severe malaria, intravenous artesunate is more rapidly acting
than intravenous quinine in terms of parasite clearance, is safer, and is simpler
to administer, but whether it can reduce mortality is uncertain.
We did an open-label randomised controlled trial in patients admitted to hospital
with severe falciparum malaria in Bangladesh, India, Indonesia, and Myanmar. We assigned
individuals intravenous artesunate 2.4 mg/kg bodyweight given as a bolus (n=730) at
0, 12, and 24 h, and then daily, or intravenous quinine (20 mg salt per kg loading
dose infused over 4 h then 10 mg/kg infused over 2-8 h three times a day; n=731).
Oral medication was substituted when possible to complete treatment. Our primary endpoint
was death from severe malaria, and analysis was by intention to treat.
We assessed all patients randomised for the primary endpoint. Mortality in artesunate
recipients was 15% (107 of 730) compared with 22% (164 of 731) in quinine recipients;
an absolute reduction of 34.7% (95% CI 18.5-47.6%; p=0.0002). Treatment with artesunate
was well tolerated, whereas quinine was associated with hypoglycaemia (relative risk
3.2, 1.3-7.8; p=0.009).
Artesunate should become the treatment of choice for severe falciparum malaria in
adults.