quinine (Rx)

Brand and Other Names:Qualaquin
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 324mg

Malaria

Uncomplicated (P falciparum)

  • 648 mg PO q8hr x 7 days

Chloroquine-resistant (P falciparum)

  • 648 mg PO q8hr x 3-7 days with concomitant tetracycline, doxycycline, or clindamycin

Chloroquine-resistant (P vivax)

  • 648 mg PO q8hr x 3-7 days with concomitant doxycycline (or tetracycline) and PO primaquine

Babesiosis (Off-label)

648 mg PO q8hr x 7 days, with concomitant PO or IV clindamycin

Dosage Modifications

Renal impairment

  • Severe: 648 mg PO once, then 324 mg PO q12hr

Hepatic impairment

  • Mild or moderate (Child-Pugh A or B): No dosage adjustment required; monitor closely
  • Severe (Child-Pugh C): Do not administer

Dosage Forms & Strengths

capsule

  • 324mg

Malaria

Uncomplicated (P falciparum)

  • 30 mg/kg/day PO divided TID x 3–7 days  
  • Should not exceed the usual adult PO dosage.

Chloroquine-resistant (P falciparum)

  • 30 mg/kg/day PO divided TID x3-7 days, with concomitant doxycycline, tetracycline or clindamycin
  • Should not exceed the usual adult PO dosage.

Chloroquine-resistant (P vivax)

  • 30 mg/kg/day PO TID x 3–7 days, with concomitant doxycyline & PO primaquine
  • Should not exceed the usual adult PO dosage.

Babesiosis (Off-label)

25 mg/kg/day PO divided TID x7 days, with concomitant oral clindamycin  

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Interactions

Interaction Checker

and quinine

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            Adverse Effects

            <1%

            Flushing of the skin

            Anginal symptoms

            Fever

            Rash

            Pruritus

            Hypoglycemia

            Epigastric pain

            Hemolysis in G6PD deficiency

            Thrombocytopenia

            Hepatitis

            Nightblindness

            Diplopia

            Optic atrophy

            Impaired hearing

            Hypersensitivity reaction

            Frequency Not Defined

            Severe headache

            Nausea

            Vomiting

            Diarrhea

            Blurred vision

            Tinnituscinchonism (risk of cinchonism is directly related to dose and duration of therapy)

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            Warnings

            Black Box Warnings

            Limited or no benefit for treatment/prevention of nocturnal leg cramps

            May cause serious and life-threatening hematologic reactions, including thrombocytopenia and hemolytic uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP)

            Chronic renal impairment associated with the development of TTP has been reported

            Contraindications

            Prolonged QT interval

            Hypersensitivity; cross-sensitivity with mefloquine or quinidine

            G6PD deficiency

            Optic neuritis, tinnitus, history of quinine-associated blackwater fever and thrombocytopenic purpura

            Thrombocytopenia

            Hemolytic uremic syndrome

            Blackwater fever

            Myasthenia gravis

            Optic neuritis

            Cautions

            FDA warns against unapproved use for leg cramps because of unpredictable serious and life-threatening hematologic reactions including thrombocytopenia and hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP)

            Quinine stimulates release of insulin from the pancreas, and patients, especially pregnant women, may experience clinically significant hypoglycemia

            QT prolongation

            • Concentration-dependent prolongation of the PR and QRS interval observed
            • At particular risk are patients with underlying structural heart disease and preexisting conduction system abnormalities, elderly patients with sick sinus syndrome, patients with atrial fibrillation with slow ventricular response, patients with myocardial ischemia or patients receiving drugs known to prolong the PR interval (eg, verapamil) or QRS interval (eg, flecainide or quinidine)
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            Pregnancy & Lactation

            Pregnancy

            No evidence that quinine causes uterine contractions at doses recommended for malaria treatment

            May stimulate the pregnant uterus at doses several-times higher than those used to treat malaria

            There are extensive published data but few well-controlled studies of quinine sulfate in pregnant women

            Published data on over 1,000 pregnancy exposures to quinine did not show an increase in teratogenic effects over the background rate in the general population; however, the majority of these exposures were not in the first trimester

            Used during pregnancy only if the potential benefit justifies the potential risk to the fetus

            Clinical considerations

            • Treatment of malaria in pregnancy is important
            • P falciparum malaria carries a higher risk of morbidity and mortality in pregnant women than in the general population
            • Pregnant women with P falciparum malaria have an increased incidence of fetal loss (including spontaneous abortion and stillbirth), preterm labor and delivery, intrauterine growth retardation, low birth weight, and maternal death
            • Hypoglycemia, due to increased pancreatic secretion of insulin, associated with quinine use, particularly in pregnant women

            Lactation

            Low levels of quinine in breastmilk; amounts ingested by infant are small and would not be expected to cause any adverse effects

            Dosage in milk is far below those required to treat an infant for malaria

            Do not use in mothers with an infant who is glucose-6-phosphate dehydrogenase (G6PD) deficient

            Relatively small amounts of quinine in tonic water ingested by breastfeeding women have caused hemolysis in G6PD-deficient infants

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of action

            Unknown; may disrupt Plasmodium DNA transcription/replication

            Pharmacokinetics

            Absorption: readily, mainly from upper small intestine

            Protein Bound: 70-95%

            Metabolism: primarily hepatic

            Half-life elimination: children: 6-12 hr; adults: 8-14 hr

            Peak Plasma Time: 1-3 hr

            Excretion: feces & saliva; urine (<5% as unchanged drug)

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            Administration

            Oral Administration

            Take with food to minimize gastric upset

            Missed dose: Instruct patient not to double the next dose; if >4 hr has elapsed since missed dose, patient should wait and take the next dose as previously scheduled

            IV Administration

            Was administered by slow IV infusion as the dihydrochloride; however, a parenteral dosage form of the drug no longer is available in the US

            Storage

            Capsules: Store at 20-25°C (68-77°F)

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.