Recurrent Malaria; Coartem Side Effects

QUESTION

I get recurrent malaria 2 to 3 times per year in Feb, March and Sept. I take Coartem which just about kills me.

I had it in early Sept this year and it was back 3 weeks later. Please can you advise how to stop it recurring. It has been a regular health problem since the 1980’s. I have had 3 Primaquine treatments to eradicate the liver parasites. The treatment did not work.

Your advice will be most appreciated.

ANSWER

Thanks for your question. First of all, is it of concern that you write that taking Coartem “nearly kills” you—do you mean you get very bad side effects? Side effects are rare with Coartem, and when they occur, they are usually mild and transient, such as headache, nausea, cough, or fever. Occasionally, patients report more significant side effects, such as tinnitus, back pain or itching. If you have more serious side effects than these, you should talk to your doctor about switching to a different formulation of malaria medication.

Given that you are based in sub-Saharan Africa, I would certainly recommend that you stick to artemisinin-based combination therapies (Coartem, for example, is a combination of artemether, which is an artemisinin-based compound, and lumefantrine), but there are different combinations, which may be more effective for you.

Second of all, in sub-Saharan Africa, Plasmodium falciparum is by far the most common form of malaria. Importantly, this parasite does NOT cause multiple episodes or recurrence, months after the initial infection, unlike Plasmodium ovale or Plasmodium vivax, both of which are found in Africa but are not nearly as common. Plasmodium falciparum infection can cause what is call “recrudescence,” which is where the number of parasites in the blood is reduced sufficiently so as not to be detectable, but then bounces back after treatment ceases, causing another bout of infection a few days or within a few weeks of the initial malarial episode—this might explain your most recent malaria experience.

Primaquine is only effective against recurring malaria when it is used to target the dormant liver stages of P. vivax and P. ovale. Therefore, in your case, it is extremely important that you are accurately diagnosed in terms of which malaria parasite you have, and each time you get infected as well. This will help determine whether you are continually being re-infected, for example with P. falciparum, or if you are indeed suffering from recurrences of P. vivax or P. ovale. If it is the latter, then primaquine is usually about 80% effective, based on global epidemiological analysis on P. vivax.

There is some evidence that strains of malaria from different regions, for example Thailand and Papua New Guinea, may be more resistant to primaquine than strains from other places. The good news about having P. vivax or P. ovale is that they are much more likely to respond to initial treatment with chloroquine, which you might tolerate better than Coartem.

So, in summary, if you have not done so already you should make sure your doctor diagnoses the species of malaria parasite that you have, either through microscopy (the different types of malaria look different under the microscope) or, preferably, through a serological blood test, which are even available as self-testing kits. At that point, alternative treatment options to Coartem can be discussed with your doctor, as well as whether it is appropriate to try primaquine again.