Following initial parenteral treatment, once the patient can tolerate oral therapy, it is essential to continue and complete treatment with an effective oral anti-malarial. Current practice is to continue the same medicine orally as given parenterally to complete a full 7 days of treatment. In non-pregnant adults, doxycycline is added to either quinine, artesunate or artemether and should also be given for 7 days. Doxycycline is preferred to other tetracyclines because it can be given once daily, and does not accumulate in renal failure. But as treatment with doxycycline only starts when the patient has recovered sufficiently, the doxycycline course finishes after the quinine, artemether or artesunate course. Where available, clindamycin may be substituted in children and pregnant women, as doxycycline cannot be given to these groups. Although following parenteral treatment with a full course of oral ACT (artesunate + amodiaquine or artemether-lumefantrine) is theoretically a good alternative, this has not been evaluated in clinical trials.
The recommendation from experts' opinion is to complete treatment in severe malaria following parenteral drug administration by giving a full course of combination therapy, ACT or quinine + clindamycin or doxycycline. Regimens containing mefloquine should be avoided if the patient presented initially with impaired consciousness. This is because of an increased incidence of neuropsy-chiatric complications associated with mefloquine following cerebral malaria.