Quinine

Aka: Quinine, Qualaquin

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II. Indications

  1. Non-Severe Malaria Treatment in Chloroquine resistant regions
    1. Combined with Doxycycline, Tetracycline or Clindamycin
    2. Alternative when Artemisinin Combination Therapy (ACT) is unavailable
  2. Do NOT use for Nocturnal Leg Cramps
    1. Low efficacy and high risk

III. Contraindications

  1. G6PD Deficiency
  2. Myasthenia Gravis
  3. Severe hepatic Impairment (Child-Pugh C)

IV. Mechanism

  1. Quinidine alkaloid extracted from cinchona tree bark
  2. Quinine inhibits Hemoglobin metabolism in Malarial blood stages (as with other antimalarials)
    1. Inhibits heme polymerase activity (resulting in toxic heme accumulation)
    2. Kills erythrocyte and gametocyte forms of Malaria
  3. Quinine has been used as an antimalarial since the 1600s
    1. Tonic water (soda, sugar and Quinine) was created to make the very bitter Quinine more palatable
    2. Tonic water was first devised by British soldiers of 1800s in Malaria-prone regions (e.g. India)
    3. Tonic water was also commonly combined with gin

V. Dosing

  1. Malaria
    1. Combined with 7 days of Doxycycline, Tetracycline or Clindamycin
    2. Adult: 648 mg salt (542 mg base) three times daily orally for 3 days (7 days in Southeast Asia)
      1. In severe Chronic Kidney Disease, after first dose, decrease to 324 mg orally every 12 hours
    3. Child: 10 mg/kg up to 648 mg salt (8.3 mg/kg up to 542 mg base) three times daily orally
  2. Severe Babesiosis
    1. Combined with Clindamycin 7 to 10 mg/kg up to 600 mg IV every 6 hours for 7 to 10 days
    2. Adult: 650 mg orally every 6 to 8 hours
    3. Child: 8 mg/kg (up to 650 mg) orally every 8 hours

VI. Adverse Effects

  1. See Quinine Toxicity
  2. Quinine Toxicity
    1. Cinchonism
      1. Vasodilation
      2. Gastrointestinal symptoms (Nausea, Vomiting, Diarrhea)
      3. Neurologic symptoms (Tinnitus, Dizziness, Headache)
    2. Severe Toxicity (esp. IV administration)
      1. Hypotension
      2. Cardiac Dysrhythmias
      3. QTc Prolongation as well as PR and QRS Duration widening
  3. Other Serious adverse effects
    1. Blackwater Fever (Malarial Hemoglobinuria)
      1. Rare Malaria treatment complication
    2. Drug-Induced Hemolysis
      1. Acute Hemolytic Anemia due to G6PD Deficiency
      2. Hemolytic Uremic Syndrome
      3. Thrombotic Thrombocytopenic Purpura

VII. Safety

  1. Considered safe in pregnancy
  2. Considered safe in Lactation
    1. Avoid in infants with G6PD Deficiency

VIII. Pharmacokinetics

  1. Oral doses peak in 1-3 hours
  2. Highly Protein bound
  3. Hepatic metabolism

IX. Drug Interactions

  1. Agents to avoid with Quinine
    1. Clarithromycin
    2. Erythromycin
    3. Rifampin
    4. Ritonavir
  2. Digoxin
    1. May increase Digoxin levels
  3. Warfarin
    1. Increased INR
  4. Antacids
    1. Decreases Quinine absorption

X. Resources

  1. Quinine Sulfate (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f567d5c7-ea5d-49a7-a035-b47208135f73

XI. References

  1. Gladwin, Trattler and Mahan (2014) Clinical Microbiology, Medmaster, Fl
  2. Hamilton (2020) Tarascon Pocket Pharmacopoeia

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Cost: Medications

quinine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
QUININE SULFATE 324 MG CAPSULE Generic $0.90 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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