Since 1991, quinidine gluconate, a class 1a anti-arrhythmic agent, has been the only parenteral antimalarial available for use in the United States.1 It is indicated for the treatment of patients with life-threatening Plasmodium falciparum malaria,2 including those who cannot tolerate oral therapy, have high-grade parasitemia, or have complications (e.g., cerebral malaria or acute renal failure).3,4
The limited availability of and delays in obtaining quinidine gluconate have contributed to adverse patient outcomes.5- 7 As newer anti-arrhythmics have replaced quinidine for many cardiac indications, some hospitals and other health-care facilities have dropped quinidine gluconate from their formularies and, as a result, fewer clinicians have had experience using the drug. Discussions among quinidine gluconate manufacturer Eli Lilly Company (Indianapolis, Indiana), CDC, the U.S. Department of Defense, and the U.S. Food and Drug Administration have resulted in the following recommendations to improve quinidine gluconate availability for acutely ill malaria patients in U.S. health-care facilities:
Before an acute need arises, hospital drug services should consider maintaining or adding quinidine gluconate to formularies or should be able to immediately locate a nearby source.
Pharmacists and clinicians requiring quinidine gluconate in hospitals in which an immediate source cannot be located should contact their local or regional distributor to request quinidine gluconate.
In clinical settings in which the need for the drug is more acute than can be met by the local or regional distributor, pharmacists and clinicians should contact Eli Lilly Company, telephone, (800) 821-0538 to arrange a rapid shipment of the drug. This telephone number, or an alternate number given to callers, is staffed 24 hours a day, 7 days a week.
If further assistance is needed in obtaining quinidine gluconate or in managing patients with malaria, contact CDC's malaria hotline, (770) 488-7788 (Monday-Friday, 8 AM to 4:30 PM eastern standard time). After business hours, weekends, and holidays, contact CDC's security station, telephone, (404) 639-2888 and ask to have the on-call person for malaria questions paged.
The following dosing recommendations for quinidine gluconate administration are provided for pharmacists and clinicians treating patients with severe or complicated malaria:
Quinidine gluconate intravenous should be administered in a monitored setting.
Prolongation of the QT interval as indicated by an electrocardiogram, ventricular arrhythmia, hypotension, and hypoglycemia can result from the use of this drug at treatment doses.
Quinidine gluconate for malaria is administered as an initial intravenous loading dose of 10 mg/kg salt (equivalent to 6.25 mg/kg quinidine base) infused over 1-2 hours. Quinidine gluconate is administered subsequently as a continuous infusion of 20 microgra µg/kg/min quinidine gluconate salt (equivalent to 12.5 µg/kg/min quinidine base).2
An alternative regimen is an intravenous loading dose of 24 mg/kg quinidine salt (equivalent to 15 mg/kg quinidine base) infused over 4 hours, followed by a maintenance infusion of 12 mg/kg of quinidine gluconate salt (equivalent to 7.5 mg/kg quinidine base) infused over 4 hours every 8 hours, starting 8 hours after the loading dose.2 These regimens have been shown to be effective with or without concomitant exchange transfusion.2
The risk for serious ventricular arrhythmia associated with quinidine is increased by bradycardia, hypokalemia, and hypomagnesemia.2 When determining whether a patient should receive a bolus dose, previous administration of other drugs that can prolong the QT interval (e.g., quinine, halofantrine, and mefloquine) should be considered.
No alternatives to quinidine exist for patients in the United States who require intravenous therapy for malaria. Acute cardiac events can be minimized by careful calculation of the loading dose and infusion rate. Consulting a cardiologist may be helpful when attempting to resume infusion in the patient who has experienced QT prolongation or hypotension associated with intravenous quinidine infusion.
Consulting a physician with experience in treating malaria is advised.
Availability and Use of Parenteral Quinidine Gluconate for Severe or Complicated Malaria. JAMA. 2001;285(6):730. doi:10.1001/jama.285.6.730-JWR0214-4-1