Contraindications and Precautions for Artesunate Use

Primary Contraindications

The World Health Organization recommends that artesunate be used with caution in patients with a significant risk of QT interval prolongation, due to the potential for increased risk of cardiac arrhythmias 1, 2
For patients from Southeast Asia, especially the Greater Mekong sub-region, with high levels of resistance to artemisinin-based combination therapies, alternative treatments should be considered, as recommended by the Centers for Disease Control and Prevention 1

The World Health Organization recommends that artesunate can be used in all trimesters of pregnancy for severe malaria, as the benefits outweigh potential risks, with a strength of evidence rated as high 2
For uncomplicated malaria in pregnancy, the American College of Obstetricians and Gynecologists endorses artemether-lumefantrine for use in all trimesters, based on moderate-quality evidence 1

The National Institutes of Health recommends that while artesunate itself is not contraindicated in G6PD deficiency, caution should be exercised due to the risk of post-artesunate delayed hemolysis, with a strength of evidence rated as moderate 2, 4
Monitoring for hemolysis, including hemoglobin, haptoglobin, and lactate dehydrogenase levels, at days 7, 14, 21, and 28 is recommended in these patients, as suggested by the European Medicines Agency 4

Post-artesunate delayed hemolysis occurs in approximately 37.4% of patients treated with artesunate, according to the World Health Organization, with a strength of evidence rated as high 1

For patients with uncomplicated malaria where artesunate is contraindicated, the Centers for Disease Control and Prevention recommend alternative treatments, including atovaquone-proguanil, with a strength of evidence rated as moderate 1, 2
For severe malaria requiring parenteral treatment where artesunate is contraindicated, the World Health Organization recommends intravenous quinine as the alternative, with a strength of evidence rated as high 2

The World Health Organization recommends monitoring parasitemia every 12 hours until decline to <1%, then every 24 hours until negative, for patients receiving artesunate for severe malaria, with a strength of evidence rated as high 4
Continuous monitoring of cardiocirculatory, pulmonary, renal, and metabolic parameters is essential for patients with severe malaria, as recommended by the National Institutes of Health, with a strength of evidence rated as moderate 4