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Antimalarial — Severe / Complicated Malaria (IV) / Nocturnal Cramps (Oral) Pregnancy: Use for malaria in pregnancy (benefit outweighs risk — untreated malaria lethal to mother and fetus); may stimulate uterine contractions at high doses — use with caution in late pregnancy

Quinine

Brand names: Quinine Sulphate

Adult dose

Dose: Severe malaria (IV loading): 20 mg/kg quinine salt IV over 4 hours (max 1400 mg), then 10 mg/kg every 8 hours; Uncomplicated malaria (oral): 600 mg every 8 hours × 5–7 days + doxycycline; Nocturnal leg cramps: 200–300 mg at bedtime
Route: IV infusion (severe malaria) or oral (uncomplicated/cramps)
Frequency: Every 8 hours (antimalarial); once daily at bedtime (cramps)
Max: 1800 mg/day (antimalarial); 300 mg/day (cramps)
Severe malaria: IV quinine or artesunate (artesunate preferred if available — WHO recommendation). Loading dose mandatory for IV (do not omit if history of quinine in last 24 hours unclear). IV must be given as slow infusion (never bolus — severe hypotension, cardiac arrhythmia). Nocturnal cramps: MHRA 2010 restricted use — only when cramps are very disabling and other measures failed; review after 4 weeks.

Paediatric dose

Dose: 20 mg/kg IV loading (over 4 hours), then 10 mg/kg every 8 hours mg/kg
Route: IV (severe malaria) or oral
Frequency: Every 8 hours
Max: 1400 mg loading dose
BNFc: same weight-based dosing as adults; IV quinine in paediatric severe malaria pending artesunate availability

Dose adjustments

Renal

Severe renal impairment: reduce maintenance dose by one third (accumulation of active metabolites)

Hepatic

Use with caution — hepatically metabolised; reduce dose in severe impairment

Paediatric weight-based calculator

BNFc: same weight-based dosing as adults; IV quinine in paediatric severe malaria pending artesunate availability

Clinical pearls

  • Artesunate is now preferred first-line for severe malaria (WHO 2015 recommendation) — faster parasite clearance, lower mortality in trials vs quinine; use quinine if artesunate unavailable or as oral step-down
  • Hypoglycaemia mechanism: quinine stimulates pancreatic beta cells to secrete insulin — monitor 4-hourly blood glucose in IV treatment; P. falciparum itself also causes hypoglycaemia; treat with dextrose
  • IV never as bolus — administer over 4 hours; ECG monitoring during IV infusion; pause if QTc >500 ms or increases by >25% from baseline
  • Cinchonism is expected at therapeutic plasma levels — tinnitus and hearing disturbance indicate therapeutic range, not toxicity per se; severe symptoms warrant level check (target 2–10 mg/L)
  • MHRA 2010: nocturnal cramps — risks outweigh benefits in most patients; restrict to severely affected cases, review every 3 months

Contraindications

  • Haemoglobinuria (blackwater fever — relative)
  • Optic neuritis
  • Myasthenia gravis
  • Tinnitus
  • QT prolongation / concurrent QT-prolonging drugs
  • G6PD deficiency (relative — risk of haemolysis)

Side effects

  • Cinchonism (tinnitus, headache, nausea, visual disturbance — dose-related)
  • QTc prolongation and arrhythmia (at therapeutic doses)
  • Hypoglycaemia (stimulates insulin secretion — monitor blood glucose)
  • Haemolytic anaemia (G6PD deficiency)
  • Thrombocytopaenia
  • Hypotension (rapid IV infusion)
  • Quinine toxicity/overdose: visual loss, deafness, arrhythmia

Monitoring

  • ECG (QTc — during IV infusion)
  • Blood glucose (4-hourly during IV)
  • Quinine plasma levels (target 2–10 mg/L)
  • FBC and platelets
  • Renal and liver function
  • Visual acuity and hearing

Reference: BNFc; BNF 90; WHO Severe Malaria Guidelines 2015; PHE Malaria Treatment Guidelines 2016; MHRA Quinine Cramps Safety Update 2010. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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