Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in children in Uganda: randomised clinical trial

Abstract

Objective: To compare the efficacy and safety of rectal artemether with intravenous quinine in the treatment of cerebral malaria in children.

Design: Randomised, single blind, clinical trial.

Setting: Acute care unit at Mulago Hospital, Uganda's national referral and teaching hospital in Kampala.

Participants: 103 children aged 6 months to 5 years with cerebral malaria.

Intervention: Patients were randomised to either intravenous quinine or rectal artemether for seven days.

Main outcome measures: Time to clearance of parasites and fever; time to regaining consciousness, starting oral intake, and sitting unaided; and adverse effects.

Results: The difference in parasitological and clinical outcomes between rectal artemether and intravenous quinine did not reach significance (parasite clearance time 54.2 (SD 33.6) hours v 55.0 (SD 24.3) hours, P = 0.90; fever clearance time 33.2 (SD 21.9) hours v 24.1(SD 18.9 hours, P = 0.08; time to regaining consciousness 30.1 (SD 24.1) hours v 22.67 (SD 18.5) hours, P = 0.10; time to starting oral intake 37.9 (SD 27.0) hours v 30.3 (SD 21.1) hours, P = 0.14). Mortality was higher in the quinine group than in the artemether group (10/52 v 6/51; relative risk 1.29, 95% confidence interval 0.84 to 2.01). No serious immediate adverse effects occurred.

Conclusion: Rectal artemether is effective and well tolerated and could be used as treatment for cerebral malaria.

Fig 1

Flow of participants through the trial

Fig 2

Kaplan-Meier survival curve for parasite clearance time for children receiving artemether or quinine. The difference in parasite clearance rates between the two treatment groups did not reach significance by the log rank test (P=0.666)