Quinine

These indications are based on manufacturer information for both originator and generic products. For product specific registered indications, please refer to product specific manufacturer information

Registered South African indications:

• Resistant strains of Plasmodium falciparum
• Muscle relaxant in myotonia congenita and myotonic contractions, and for nocturnal muscle cramps

Contraindications

• Hypersensitivity to the active ingredient or any of its excipients  
• Haemoglobinuria
• Optic neuritis
• Tinnitus
• Myasthenia gravis

Cautions

• Pregnancy
• Breastfeeding
• Moderate to severe renal impairment
• Severe hepatic impairment
• Serious cardiac disorders
• Glucose-6-Phosphate dehydrogenase deficiency
• Thrombocytopenia
• Cinchonism
• Atrial fibrillation  
• Treatment of leg cramps

Forms avail. in SA and covered in this monograph: inj, tab

Dosages below include:

• South African Standard Treatment Guideline indications and dosages
• South African registered indications and dosages & Indications and dosages registered in other jurisdictions 

Infections caused by: Plasmodium falciparum

Specific doses based on individual indications

Please note that the dosages below should be used in combination with regional guidelines, taking into account local antibiotic sensitivities

South African Standard Treatment Guideline indications and dosages

P. falciparum malaria - severe
- If parenteral artesunate is not available

• IV: Loading dose: 20mg/kg, as an infusion over 4hrs; Then after 8hrs: Maintenance: 10mg/kg, 8hrly as an infusion over 4hrs until clinical improvement and patient can take oral therapy
  (STG, Adult 2019)

IM: Inject half the volume immediately as a single dose in each thigh (anterolateral) to reduce pain and prevent sterile abscess formation

South African registered indications and dosages &
Indications and dosages registered in other jurisdictions

P. falciparum malaria (Additional agent required)

• Oral (tab): 600mg, 8hrly; Treatment duration: 7-10 days

Nocturnal cramps 

• Oral (tab): 300mg, dly at night; Treatment duration: 4 week trial

Treatment should be stopped after the 4 week trial if there is no benefit
Treatment should be interrupted at approximately three monthly intervals to assess the need for continuation of treatment with quinine

Paed. forms avail. in SA and covered in this monograph: inj, tab

Paed. dosages below include:

• South African Standard Treatment Guidelines indications and dosages

Infections caused by: Plasmodium falciparum

Specific doses based on individual indications

Please note that the dosages below should be used in combination with regional guidelines, taking into account local antibiotic sensitivities

South African Standard Treatment Guidelines indications and dosages

Uncomplicated P. falciparum malaria - non-severe (Additional agent required)

• <5kg: Oral (tab): Initial dose: 10mg/kg, 8hrly; Treatment duration: 7-10 days 
  (STG, Paed. 2017)

- Unable to tolerate oral treatment

• IV: 10mg/kg, 8hrly, as an infusion over 4-6hrs
  (STG, Paed. 2017)

Complicated P. falciparum malaria - severe

- Urgent

• IV: Loading dose: 20mg/kg, as an infusion over 4hrs; Maintenance: 10mg/kg, 8hrly as an infusion over 4-6hrs, until able to tolerate oral therapy
  (STG, Paed. 2017)

- Switch to oral once able to swallow, 2-3 days after initiating IV quinine (Additional agent required)

• <5kg: Oral (tab): 10mg/kg, 8hrly; Treatment duration: 7-10 days
  (STG, Paed. 2017)

See additional prescribing points for administration directions

Pregnancy

• Caution
• Large doses of quinine can induce abortion. Quinine may cause congenital abnormalities of the CNS and extremities. Following administration of large doses during pregnancy, phototoxicity and deafness have been reported in neonates. Quinine sulfate should not be used during pregnancy unless the benefits outweigh the risks
• Treatment of falciparum malaria: Pregnancy in a patient with malaria is not generally regarded as a contraindication to the use of quinine. As malaria infection is potentially serious during pregnancy and poses a threat to the mother and foetus, there appears to be little justification in withholding treatment in the absence of a suitable alternative
• Prophylaxis of nocturnal leg-cramps: Quinine sulfate should not be used during pregnancy to treat cramps

Breastfeeding

• Caution; not recommended
• Quinine sulfate is excreted in breast milk, but no problems in humans have been reported. Infants at risk for glucose-6-phosphate dehydrogenase deficiency should not be breastfed until this disease can be ruled out. However, quinine sulfate should not be given to nursing mothers unless the benefits outweigh the risks

Renal Impairment

• Mild: No dose adjustment recommended
• Moderate to severe: Caution; dose adjustment recommended
  In severe cases of malaria, the calculated dose should be administered without dose adjustment
  Loading doses (when necessary) must not be adjusted and should be administered in full as calculated mg/kg

Hepatic Impairment

• Mild to moderate (Child-Pugh class A and B): No dose adjustment recommended
• Severe (Child-Pugh class C): Caution; dose adjustment recommended
  Use with high caution; Increase frequency of dosing in case of elevated serum transaminases (especially ALT) two-folds or more above the reference
  In severe cases of malaria, the calculated dose should be administered without dose adjustment
  Loading doses (when necessary) must not be adjusted and should be administered in full as calculated mg/kg

Elderly

• No dose adjustment recommended

Porphyria Information

• Possibly porphyrinogenic (PSP)

Drugs in Sport

• Permitted - No warnings

Central Nervous System Disorders

• Agitation
• Confusion
• Headache
• Vertigo
• Excitement
• Loss of consciousness
• Coma
• Death 

Cardiovascular Disorders

• Atrioventricular conduction disturbances
• Fall in blood pressure coupled with a feeble pulse
• Prolongation of the QT interval
• Widening of the QRS complex 
• T wave flattening 

Respiratory Disorders

• Bronchospasm
• Dyspnoea 
• Asthma

Gastrointestinal Disorders

• Diarrhoea
• Nausea and vomiting
• Abdominal pain 

Genitourinary Disorders

• Renal insufficiency 
• Acute renal failure 
• Oliguria
• Spontaneous miscarriage

Endocrine and Metabolic Disorders

•  Hypoglycaemia 

Musculoskeletal Disorders

• Muscle weakness 
• Aggravation of myasthenia gravis

Skin and Subcutaneous Tissue Disorders

• Flushing
• Rash
• Urticaria
• Eczematous dermatitis
• Oedema
• Erythema
• Lichen planus
• Pruritis
• Photosensitivity
• Hot and flushed skin

Immune, Blood and Lymphatic System Disorders

• Thrombocytopenia
• Intravascular coagulation
• Hypoprothrombinaemia
• Haemoglobinuria
• Haemolytic-uremic syndrome
• Pancytopenia
• Haemolysis agranulocytosis 
• Thrombocytopenic purpura 
• Angioneurotic oedema
• Fever

Sensory Disorders

• Blurred vision
• Defective colour perception
• Visual field constriction
• Tinnitus
• Impaired hearing

• CYP3A4 inhibitors
• CYP3A4 inducers
• Flecanide
• Mefloquine 
• Amantadine
• Ciclosporin
• Cardiac glycosides
• QT prolonging agents
• Antiarrhythmics
• Antibacterials
• Anticoagulants
• Antihistamines
• Antimalarials
• Antipsychotics
• Hypoglycaemics
• Suxamethonium
• Cimetidine

• Cardiac monitoring (inj)
• Blood glucose (inj)

Specific cases may require

• Ophthalmic examination
• Full blood count
• Hepatic function
• ECG

Administration directions: Adults

• IV infusion: Dilute with 5% dextrose; Infuse over at least 4hrs
• IM bolus: May be given if IV infusion is not possible. Dilute with 0.9% sodium chloride to 60-100mg/ml. Inject half into each thigh

Administration directions: Paediatrics

• IV infusion: Dilute with 5-10ml/kg 5% dextrose or 0.9% sodium chloride; Infuse over 4hrs (loading dose), over 4-6hrs (maintenance dose)

Injections 300mg/1ml - EML (Primary)

The exact mechanism of action of quinine is unclear. It may interfere with lysosome function or nucleic acid synthesis in the malaria parasite and interferes with the parasite's ability to break down and digest haemoglobin.

Spectrum of activity: Plasmodium falciparum

Tablet 300mg

• Aspen quinine (Pharmacare)

Injections (per 1ml) 300mg

• Adco-quin dihyd (Adcock)
• Quinine dihydrochloride-fresenius (Fresenius Kabi)