Quinine Sulfate

A to Z Drug Facts

 Action Causes pH elevation in intracellular organelles of parasites; also has skeletal muscle relaxant effects and cardiovascular effects similar to those of quinidine.

 Indications Treatment of chloroquine-resistant falciparum malaria; alternative treatment for chloroquine-sensitive strains of P. falciparum, P. malariae, P. ovale, and P. uivae. Unlabeled use(s): Prevention and treatment of nocturnal recumbency leg cramps.

 Contraindications G-6-PD deficiency; optic neuritis; tinnitus; history of blackwater fever and thrombocytopenic purpura associated with previous quinine ingestion; pregnancy.

 Route/Dosage

Chloroquine-Resistant P. Falciparum Malaria

ADULTS: PO 650 mg q 8 hr for 5 to 7 days. CHILDREN: PO 25 mg/kg/day in divided doses q 8 hr for 5 to 7 days.

Chloroquine-Sensitive Malaria

ADULTS: PO 600 mg q 8 hr for 5 to 7 days. CHILDREN: PO 10 mg/kg q 8 hr for 5 to 7 days.

Nocturnal Leg Cramps

ADULTS: PO 260 to 300 mg at bedtime.

 Interactions

Aluminum-containing antacids: Causes delayed or decreased quinine absorption. Anticoagulants, oral: May cause depression of hepatic enzyme system that synthesizes vitamin K-dependent clotting factors and may enhance action of oral anticoagulants. Cimetidine: May reduce quinine's clearance and prolong its half-life in body. Digoxin: May cause increased digoxin serum concentration. Mefloquine: May cause ECG abnormalities or cardiac arrest and may increase risk of convulsions. Do not use concurrently. Delay administration 12 hr after last dose of quinine. Neuromuscular blocking agents: May potentiate neuromuscular blockade and may result in respiratory difficulties. Urinary alkalinizers: May increase quinine serum concentrations and potentiate toxicity.

 Lab Test Interferences Urinary 17-ketogenic steroids may have elevated values with Zimmerman method.

 Adverse Reactions

CV: Anginal symptoms. CNS: Vertigo; dizziness; headache; fever; apprehension; restlessness; confusion; syncope; excitement; delirium; hypothermia; seizures. EENT: Visual disturbances (eg, photophobia, blurred vision with scotomata, night blindness, amblyopia, diplopia, diminished visual fields, mydriasis, optic atrophy) tinnitus; deafness. GI: Nausea; vomiting; diarrhea; epigastric pain. GU: Renal tubular damage; anuria. HEPA: Hepatitis. HEMA: Acute hemolysis; hemolytic anemia; thrombocytopenic purpura; agranulocytosis; hypoprothrombinemia. OTHER: Cinchonism (headache, tinnitus, nausea, diarrhea, disturbed vision, skin, CV and CNS symptoms at very high doses); hypersensitivity (rash, pruritus, flushing, sweating, facial edema, asthmatic symptoms).

 Precautions

Pregnancy: Category X. Lactation: Excreted in breast milk. Cardiac disease: Patients with cardiac arrhythmias may have exacerbation of symptoms with quinine, which acts similarly to quinidine. May cause cardiotoxicity. In patients with atrial fibrillation, quinine requires same precautions as for quinidine. Hemolysis: Has been associated with G-6-PD deficiency. Discontinue immediately if hemolysis appears.

 Administration/Storage

• Give with food or after meals to minimize GI irritation; give bedtime dose with milk or snack.
• Administer around clock (every 8 hr) to maintain serum drug levels if being used to treat malaria.
• Administer at bedtime if being used to treat or prevent nocturnal leg cramps.
• Do not crush tablets; have patient swallow tablets whole.
• Store in tight, light-resistant container.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Determine whether patient has any contraindications to quinine (eg, G-6PD deficiency, pregnancy).
• Obtain baseline ECG, hepatic studies, and CBC prior to therapy.
• Assess pulse and ECG during therapy to detect arrhythmias.
• Assess for evidence of hematological abnormalities (eg, sore throat, fever, bleeding/bruising, fatigue, weakness).
• Assess for the following signs of cinchonism: Blurred vision, headache, tinnitus, vertigo, lightheadedness, nausea. Report these adverse effects immediately to the health care provider.

 Patient/Family Education

• Caution patient that this medication must not be taken during pregnancy or when pregnancy is possible. Advise patient to use reliable form of birth control while taking this drug.
• If medication is being used to treat malaria, advise patient to take medication around clock and to take full course of treatment even if feeling better.
• Emphasize importance of medical follow-up when this course of therapy has been completed to ensure that therapy has been successful.
• If medication is being used to treat nocturnal leg cramps, advise patient to take drug before bedtime.
• Instruct patient to consult health care provider before combining any new medications with this drug.
• Advise patient to take medication with or after meals or snack to minimize GI distress.
• Instruct patient to report the following symptoms to the health care provider: Flushing, itching, rash, fever, difficulty breathing, vision problems, ringing in ears, diarrhea, nausea/vomiting, vertigo.
• Advise patient that drug may cause dizziness and vision problems, and to use caution while driving or performing other tasks requiring mental alertness.
• Instruct patient not to take otc medications (especially cold preparations) without consulting health care provider.

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Copyright © 2003 Facts and Comparisons
David S. Tatro
A to Z Drug Facts