Dosing & Uses
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)
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
Interactions
Interaction Checker
No Results

Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor

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)
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)
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.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)
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
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