Adult: For severe or complicated cases, or when the patient is unable to take the oral form: As quinine dihydrochloride: Loading dose: 20 mg/kg (Max: 1,400 mg) via slow IV infusion over 4 hours, then start the maintenance infusion 8 hours after the loading dose. Alternatively for patients in the ICU, 7 mg/kg loading dose via IV infusion over 30 minutes may be given, followed immediately by the 1st maintenance infusion. Maintenance dose: 10 mg/kg (Max: 700 mg) via slow IV infusion over 4 hours given every 8-12 hours. Reduce the maintenance dose to 5-7 mg/kg if >48 hours of parenteral therapy is required. If the patient has received other antimalarials in the last 12-24 hours, a loading dose should not be given. All doses may be given via IM inj only if IV infusion is not feasible; the loading dose must be divided into 2 injection sites, preferably each anterior thigh. Switch to oral therapy as soon as possible. Dosage and treatment recommendations may vary among individual products and between countries (refer to specific product or local guidelines). Child: For severe or complicated cases, or when the patient is unable to take the oral form: As quinine dihydrochloride: Same as adult dose. Doses are given via slow IV infusion at a rate not exceeding 5 mg/kg/hour. If IV infusion is not feasible, doses may be given via IM inj; the loading dose must be divided into 2 injection sites, preferably each anterior thigh. Switch to oral therapy as soon as possible. Dosage and treatment recommendations may vary among individual products and between countries (refer to specific product or local guidelines).
Oral Chloroquine-resistant falciparum malaria
Adult: Doses are expressed in terms of quinine salt (100 mg quinine base is equivalent to approx 121 mg quinine sulfate or 169 mg quinine bisulfate). For uncomplicated cases: As quinine sulfate or quinine bisulfate tab: 600 mg 8 hourly for 7 days. Alternatively as quinine sulfate cap: 648 mg 8 hourly for 7 days. All doses may be in combination with or followed by other antimalarial agents (e.g. doxycycline, clindamycin). Dosage and treatment recommendations may vary among individual products and between countries (refer to specific product or local guidelines). Child: Doses are expressed in terms of quinine salt (100 mg quinine base is equivalent to approx 121 mg quinine sulfate or 169 mg quinine bisulfate). For uncomplicated cases: As quinine sulfate or quinine bisulfate tab: 10 mg/kg (Max: 600 mg) 8 hourly for 7 days in combination with other appropriate antimalarial agents. Dosage and treatment recommendations may vary among individual products and between countries (refer to specific product or local guidelines).
Oral Nocturnal leg cramps
Adult: As quinine sulfate: 200 mg once daily at bedtime. Max: 300 mg daily. As quinine bisulfate: 300 mg once daily at bedtime. Discontinue treatment if there is no benefit after the initial 4-week trial. Dosage and treatment recommendations may vary among individual products and between countries (refer to specific product or local guidelines).
What are the brands available for Quinine in Malaysia?
Malacam
Malakin
Renal Impairment
Oral:
Dosage reduction or increased dose interval may be required.
Intravenous/Intramuscular:
Severe: Dosage reduction may be required.
Hepatic Impairment
Oral:
Dosage reduction or increased dose interval may be required.
Intravenous/Intramuscular:
Severe: Dosage reduction may be required.
Administration
Quinine Should be taken with food.
Reconstitution
Concentrated solution for inj: IV infusion: Dilute with 500 mL NaCl 0.9% solution or dextrose 5% water. IM inj: Dilute in NaCl 0.9% solution to make a 60-100 mg/mL concentration.
Incompatibility
IV infusion: Incompatible with alcuronium chloride, atracurium besylate, mivacurium chloride, pancuronium bromide, pipecuronium bromide, rocuronium bromide, suxamethonium chloride, tubocurarine chloride, vecuronium chloride, amiodarone, diuretics (particularly furosemide), mannitol, heparin, and IV ketamine.
Contraindications
Hypersensitivity to quinine, quinidine or mefloquine. History of possible hypersensitivity reactions associated with previous use of quinine (including blackwater fever, haemolytic uraemic syndrome, immune thrombocytopenia, thrombotic thrombocytopenic purpura, or thrombocytopenia); haemolysis or haemoglobinuria, prolonged QT interval, tinnitus, optic neuritis, myasthenia gravis.
Special Precautions
Patient with conditions that predispose to arrhythmias or QT interval prolongation, atrial fibrillation or flutter, AV block, cardiac conduction defects, or other serious heart disease; electrolyte disturbances; G6PD deficiency. Before using quinine for nocturnal leg cramps, carefully weigh the risks against the potential benefits; consider quinine only when cramps are frequent or very painful, other treatable causes have been excluded, and non-pharmacological interventions are ineffective. Recommendations for using quinine in nocturnal leg cramps may vary between countries (refer to detailed local guidelines). Renal and hepatic impairment. Children and elderly. Pregnancy and lactation.
Adverse Reactions
Significant: Severe hypersensitivity reactions (e.g. anaphylactic shock, Stevens-Johnson syndrome), blackwater fever, acute interstitial nephritis, neutropenia, granulomatous hepatitis; QT interval prolongation; cinchonism; hypoglycaemia; aggravation of myasthenia gravis; acute haemolytic anaemia (especially to patients with G6PD deficiency); pain, focal necrosis and abscess formation (when given via IM). Blood and lymphatic system disorders: Agranulocytosis, pancytopenia, intravascular coagulation. Cardiac disorders: AV conduction disturbances. Ear and labyrinth disorders: Tinnitus, impaired hearing, vertigo. Eye disorders: Blurred vision, visual field constriction, defective colour perception, blindness. Gastrointestinal disorders: Nausea, vomiting, abdominal pain, diarrhoea. General disorders and administration site conditions: Fever. Musculoskeletal and connective tissue disorders: Muscle weakness. Nervous system disorders: Headache. Psychiatric disorders: Agitation, confusion. Renal and urinary disorders: Renal insufficiency, acute renal failure. Respiratory, thoracic and mediastinal disorders: Asthma, bronchospasm, dyspnoea. Skin and subcutaneous tissue disorders: Rash, urticaria, pruritus, photosensitivity. Vascular disorders: Flushing. Potentially Fatal: Immune thrombocytopenia, thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome; severe hypotension, torsades de pointes, ventricular fibrillation.
Monitor CBC with platelet count, LFTs, blood glucose, ECG, and blood pressure (particularly for parenteral administration). Perform ophthalmologic examination as clinically indicated. Closely monitor patients receiving parenteral doses for signs of cardiotoxicity. Assess for signs and symptoms of hypersensitivity reactions.
Overdosage
Symptoms: Nausea, vomiting, headache, visual impairment, tinnitus, deafness, vasodilation, hypokalaemia, hypoglycaemia, convulsions, impaired consciousness, respiratory depression, QT prolongation, ventricular arrhythmia, cardiogenic shock, renal failure, coma, and miscarriage. Management: Symptomatic and supportive treatment. Consider the administration of activated charcoal within 1 hour of ingesting doses >30 mg/kg quinine base or any amount in children <5 years; multiple doses will enhance elimination. Maintain blood pressure, respiration, and renal function. Treat arrhythmia, hypoglycaemia, acidosis, and convulsions. Monitor cardiac rhythm or conduction, blood glucose, serum electrolytes, and visual acuity.
Drug Interactions
Increased risk of ventricular arrhythmia with other agents known to prolong QT interval (e.g. amiodarone, halofantrine, moxifloxacin, astemizole, terfenadine, pimozide, thioridazine, cisapride). Increased risk of seizures with mefloquine. May potentiate the effects of anticoagulants and neuromuscular blockers. Increased risk of hypoglycaemia with oral hypoglycaemic agents. May reduce the renal clearance of amantadine. Decreased plasma concentrations with CYP3A4 inducers (e.g. carbamazepine, phenobarbital, phenytoin, rifampicin). Increased plasma levels with strong CYP3A4 inhibitors (e.g. ritonavir) or urinary alkalinisers (e.g. acetazolamide, sodium bicarbonate). May delay or decrease absorption with aluminium- and/or magnesium-containing antacids. May reduce the plasma levels of ciclosporin. May increase the plasma concentration of digoxin. Increased risk of myopathy and rhabdomyolysis with atorvastatin.
Lab Interference
May cause positive direct Coombs test, false-positive result with urine detection of opioids, and false elevation of urinary 17-ketogenic steroids (using Zimmerman method) and catecholamines. May interfere with qualitative and quantitative urine dipstick protein assays.
Action
Description: Mechanism of Action: Quinine, a cinchona alkaloid and levorotatory isomer of quinidine, is 4-methanolquinoline antimalarial agent. Its exact mechanism of action is not yet determined, but it may inhibit nucleic acid synthesis, protein synthesis, and glycolysis in malaria parasites. Quinine may depress oxygen uptake, decrease carbohydrate metabolism, and intercalate into DNA, resulting in the disruption of the parasite's replication and transcription. Pharmacokinetics: Absorption: Rapidly and almost completely absorbed from the gastrointestinal tract. Bioavailability: 78-95% (healthy patients). Time to peak plasma concentration: Approx 1-3 hours (oral). Distribution: Widely distributed throughout the body. Poorly penetrates CSF (approx 2-7% of plasma concentration). Crosses the placenta; enters breast milk (small amounts). Volume of distribution: 2.5-7.1 L/kg (varies depending on infection severity). Plasma protein binding: Approx 70% (healthy patients); ≥90% (malaria patients). Metabolism: Extensively metabolised in the liver via oxidative CYP450 pathways primarily by CYP3A4 to form 3-hydroxyquinine (major metabolite) and other metabolites. Excretion: Mainly via urine (approx 20% as unchanged drug); increases in acidic urine. Elimination half-life: Approx 11 hours (healthy patients).
Chemical Structure
Quinine Source: National Center for Biotechnology Information. PubChem Compound Summary for CID 3034034, Quinine. https://pubchem.ncbi.nlm.nih.gov/compound/Quinine. Accessed June 25, 2025.
Storage
Store between 20-25°C. Protect the intact vial from light.
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