Quinine Sulfate

Innovator's Monograph

Indications

Quinine Sulfate, is an antimalarial drug indicated only for treatment of uncomplicated Plasmodium falciparum malaria. Quinine sulfate has been shown to be effective in geographical regions where resistance to chloroquine has been documented 

Quinine Sulfate oral capsules are not approved for:
  • Treatment of severe or complicated P. falciparum malaria.
  • Prevention of malaria.
  • Treatment or prevention of nocturnal leg cramps
Quinine Dihydrochloride is indicated for the acute treatment of malaria. It may also be used in the treatment of Babesiosis in conjunction with clindamycin.

Therapeutic Class

Anti-malarial drugs

Pharmacology

Quinine is a cinchona alkaloid and a 4-methanolquinoline. It rapidly acts on blood schizontocide by interfering with lysosomal function or nucleic acid synthesis in the Plasmodia spp. It has no activity against exoerythrocytic forms.

Dosage

Intravenous:
  • Adult: Initially, 20 mg/kg to max 1.4 g over 4 hr with maintenance infusion started after 8 hr. Maintenance infusions: 10 mg/kg to max 700 mg over 4 hr 8 hrly. Loading dose should not be given if patient has received quinine, quinidine, halofantrine or mefloquine during the previous 24 hr.
  • Child: ≤5 mg/kg/hr by slow IV infusion.
Oral:
  • Adult: 648 mg given every 8 hr for 7 days.
  • Child: ≥8 yr 10 mg/kg 8 hrly for 7 days.

Administration

Should be taken with food. Take with food to minimise GI discomfort.

Interaction

Reduced renal clearance of amantadine. Reduced clearance with cimetidine. Increased anticoagulant effect of warfarin and other anticoagulants. Reduced plasma levels of ciclosporin. Increased plasma levels of digoxin. Increased risk of myopathy and rhabdomyolysis with atorvastatin. May enhance hypoglycaemic effects of oral antidiabetics.

Contraindications

Hypersensitivity to quinine, mefloquine or quinidine. Patients with nocturnal leg cramps; prolonged QT interval, tinnitus or optic neuritis, myasthenia gravis, G6PD deficiency, haemolysis and who had suffered from blackwater fever. Concomitant use with ritonavir, mefloquine, rifampicin, class IA and class III antiarrhythmic agents, neuromuscular blocking agents, other drugs known to cause QT prolongation, and Al- and/or Mg-containing antacids.

Side Effects

Headache, nausea, disturbed vision, impaired hearing, tinnitus, abdominal pain, vomiting, diarrhoea, vertigo; flushing skin with intense pruritus, urticaria; fever, dyspnoea, agranulocytosis, palpitations, rashes; myalgia, muscle weakness, asthma, asthenia, disorientation, angioedema; haemoglobinuria; hypoprothrombinaemia, hypoglycaemia, hypotension, renal failure.

Pregnancy & Lactation

Pregnancy Category C. Either studies in animals have revealed adverse effects on the foetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the foetus.

Precautions

Patients with cardiac conduction defects, heart block or AF. Pregnancy and lactation.

Overdose Effects

Symptoms: GI effects, CNS disturbances, oculotoxicity, cardiotoxicity,; tinnitus, abdominal pain, diarrhoea, vertigo, pulmonary oedema, hypotension, sweating, flushing, nausea, vomiting, headache, slightly disturbed vision, deafness, vasodilatation and adult resp distress syndrome.

Management: Administer multiple dose of activated charcoal within 1 hr or perform gastric lavage. Symptomatic (e.g. maintaining BP, respiration and renal function, treating arrhythmias) and supportive treatment.

Use in Special Population

Renal Impairment:
  • Oral: Severe: Initially, 648 mg followed after 12 hr by maintenance doses of 324 mg 12 hrly.
  • Intravenous: Severe: Reduce maintenance dose to 5-7 mg/kg of quinine salt 8 hrly.
Hepatic Impairment:
  • Mild to moderate: No dosage adjustment needed.
  • Intravenous: Severe: Reduce maintenance dose to 5-7 mg/kg of quinine salt 8 hrly.

Reconstitutions

Dilute in NaCl 0.9% to a concentration of diHCl 60-100 mg/mL.

Storage Conditions

Store between 20-25° C. Protect from light.

Available Brand Names