With the introduction of Dihydroartemisinin‐piperaquine (DHAP) and artesunate-pyronaridine (ASPY) on the list of anti-malarial drugs available in Rwanda, the number of treatments that can be transcribed for patients in the country has increased tremendously.

Among the available drugs on the market include some antimalarials people are likely to have forgotten about, including, Quinine, Fansidar and Chloroquine, which were the main drugs used to treat malaria in the 80’s, 90’s and early 2000’s.

While you might no longer get them on the prescription as they were then, these medicines are still actively used to treat malaria, except that they have to be combined with other artemisinin-based therapies for efficacy.

Following a reported surge in new malaria cases and growing drug resistance, it is important to know which drugs one might take or have administered, for those who get admitted due to the disease, which is increasingly becoming hideous and resistant to treatment.

With the addition of new antimalarial drugs to combat malaria resistance to already existing drugs on the market, the list contains a variety of medicines, highlighted in the National Malaria Treatment Guideline, which doctors can prescribe.

While in some countries anti-malarial drugs can be obtained in shops, in Rwanda it is a requirement for pharmacies to consider a doctor’s prescription before handing out the drugs to those who need them.

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As the epidemiology of malaria continues to evolve and become more resistant, the efficacy of the medicine one must take must be determined by doctors, after conducting tests, which is why it is highly recommended that the anti-malarial drugs are prescribed by a health professional.

As of today, Artemisinin-based Combination Therapies (ACTs) remain the best first line available treatment for malaria, due to their efficacy. Below we look at how anti-malarial drugs have evolved in Rwanda and which ones are currently available on the market.

Artemether/Lumefantrine (Coartem)

Artemether/lumefantrine, locally known by the brand name Coartem, is the most common anti-malaria drug prescribed in Rwanda. Coartem is a first line, fixed-dose drug which is the most prescribed by doctors when they detect the malaria parasite in the body.

It has a combination of artemether and lumefantrine, which acts as a blood schizonticide.

The artemisinin based-derivative drug is and remains one of the most efficient drugs to treat the disease caused by Plasmodium falciparum protozoa, which is transmitted by the female anopheles mosquito.

The normally round, yellow tablets with bevelled edges, contains the two active substances, Artemether and lumefantrine; the former extracted from the plant Artemisia annua, while the latter is a racemic mixture of a synthetic fluorene derivative.

According to available specification, one 20 mg/120 mg tablet contains 20 mg artemether and 120 mg lumefantrine while the one of 80 mg/480 mg contains 80 mg artemether and 480 mg lumefantrine, as well as other compounds.

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While the drug varies in appearance, based on the manufacturer, the ones available in Rwanda are assessed and approved by the Rwanda Food and Drug Authority (FDA), just like other drugs, to ensure quality and efficacy.

The dosage is determined by the doctor upon diagnosis, based on the age, size and condition of the patient, among other determinants. Dosage in adults and children weighing 35 kg and above or more than 12 years of age, a standard 3 days treatment schedule with a total of 6 doses is administered.

Artesunate + Amodiaquine (AS + AQ)

In early 2002, Rwanda stopped using chloroquine as the first line drug to treat malaria due to increasing resistance of the disease to the drug.

For several decades, Chloroquine, which was renowned for triggering many undesired side effects, like body itching and headaches, was the most common treatment for malaria, mainly because it was affordable, easy to use, and effective.

However, the malaria parasites became more resistant to chloroquine and it was no longer used to treat malaria. Rwanda switched to amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP), commonly known by the market name Fansidar.

While Fansidar seemed more effective in treating malaria than chloroquine, it also had its own side effects that made many dreaded, including stomach pain, feeling full, hair loss, headache, muscle weakness, depression, nervousness and ringing in the ears, among other side effects.

In 2005, Rwanda began using artemisinin-based combination therapies, starting with Artesunate-amodiaquine (AS-AQ), which combines the two elements -the latter which was what was known as ‘Fansidar’.

While Artesunate + Amodiaquine (AS + AQ) is not often prescribed for outpatients, it is still used among the first line drugs to treat malaria, especially among children.

Several studies in Rwanda, Ghana and Côte d'Ivoire showed that the combination has an efficacy rate of up to 97.7 per cent when it comes to treating malaria in children. It is mainly administered intravenously.

Artesunate + Sulfadoxine-Pyrimethamine (AS + SP)

As the malaria parasite evolved and became more difficult to treat, Rwanda added more ACTs approved by the World Health Organisation (WHO) to the list, including Artesunate + Sulfadoxine-Pyrimethamine (AS + SP), which was also sold under the brand name ‘Fansidar’.

The combination was used to treat malaria in Rwanda for the past two decades or so, after a randomized controlled trial in Kigali and some other parts of the country, found that AS + SP had satisfactory results, including adequate clinical and parasitologic response within 28 days of at least 90.

The combination also had no side effects and was low priced. While it is no longer the first option, the combination which contains sulfadoxine and pyrimethamine, is still typically used along with other antimalarial medication to treat malaria cases, especially among children, in places like Bugesera and others where it was found to be effective.

Quinine Sulphate

Apart from Chloroquine and Fansidar, Quinine pills were the other most common treatments for severe, malignant malaria, known as malignant tertian. So to speak, it was the ‘dangerous substitute’ where other antimalarials failed.

As of today, Quinine Sulphate remains the first line treatment of malaria among pregnant women, especially during the first trimester. The drug is available in tablets or intravenous form.

It is also important to note that Quinine Sulphate is still crucially used to treat and prevent nocturnal leg cramps in adults and elderly.

Artesunate rectal or injection

In the event other forms of treatment fail, especially among children, WHO recommends other forms of treatment such as Artesunate, which can be administered through an injection, intravenous (IV) or through the rectum.

Artesunate plays a key role in reducing fatality, before a malaria patient is transferred to a referral facility. It plays an important role in reducing mortality, particularly among severely ill young children.

Dihydroartemisinin-piperaquine (DHAP)

This is one of the new anti-malarial drugs recommended by the WHO, which Rwanda recently added on the list of drugs available in the country, to combat resistance to treatment.

DHAP was in 2020 adopted as a second-line antimalarial for treatment of uncomplicated malaria after it showed positive results in Ghana where it was tested. It was found to have a therapeutic efficacy of 93.3 percent using a 28-day follow-up schedule- well below the scheduled 42 days of observation.

The drug showed high efficacy levels especially among children aged 6 months to 9 years, prompting the global health body to add it on the list of effective ACTs.

Last week, Rwanda began distributing the drug in different parts of the country where an increase in malaria cases has been detected, as well as drug resistance.

Artesunate-Pyronaridine (ASPY)

It is one of the latest drugs to be added on the list of anti-malarial therapies in the wake of drug resistance on the African continent and Asia. Along with DHAP, Rwanda is looking to rely on these new drugs to nip in the bud drug resistance.

It is considered the most novel of ACTs and seen as a game changer in dealing with artemisinin resistance and a saviour for artemisinin derivatives in ACTs.

Several studies have found that Pyronaridine‐artesunate is more effective in treating uncomplicated P falciparum malaria, showing higher efficacy levels than other existing ACTs.