Quinine is a natural white crystalline alkaloid having antipyretic (fever-

reducing), antimalarial,analgesic (painkilling), anti-inflammatory properties and a bitter taste.

It is a stereoisomer of quinidine which, unlike quinine, is an anti-arrhythmic.
Though it has been synthesized in the lab, the bark of the cinchona tree is the only known
natural source of quinine. Quinine was the first effective treatment for malaria caused
by Plasmodium falciparum, appearing in therapeutics in the 17th century

Two types:

Antiprotozoal—

antimyotonic—

What it is for:

Malaria (treatment)—Quinine is indicated in conjunction with doxycycline, clindamycin, or

sulfadoxine/pyrimethamine combination in the treatment of uncomplicated chloroquine-
resistant malaria caused by Plasmodium falciparum and [Plasmodium vivax] {02} {07} {19}.

Note: The treatment of chloroquine-resistant malaria caused by P. vivax requires higher

doses of quinine {02}. Therefore, if quinine is considered for the treatment of chloroquine-
resistant malaria caused by P. vivax , expert advice from an infectious or tropical disease
specialist should be sought {02}.

[Leg cramps (prophylaxis and treatment)]—Quinine is indicated in the prophylaxis and

treatment of nocturnal recumbency leg muscle cramps {02} {11}, including those associated with
arthritis, diabetes, varicose veins, thrombophlebitis, arteriosclerosis, and static foot
deformities.

[Babesiosis (treatment)]1—Quinine is used concurrently with clindamycin in the treatment of

severe babesiosis caused by Babesia microti {44} {45} {46}.

Mechanism of action/Effect:

Antiprotozoal—The precise mechanism of action of quinine in malaria has not been

determined but may be based on its ability to concentrate in parasitic acid vesicles, causing
an elevation of pH in intracellular organelles. This is thought to disrupt the intracellular
transport of membrane components and macromolecules, and phospholipase activity {14}.
Quinine has a schizonticidal action. Its ability to concentrate in parasitized erythrocytes may
account for its selective toxicity against the erythrocytic stages of the four malarial parasites,
including Plasmodium falciparum strains resistant to chloroquine. The drug is also
gametocidal against Plasmodium vivax and Plasmodium malariae {14} {47}.

Antimyotonic—Quinine increases the refractory period of skeletal muscle by direct action on

the muscle fiber and the distribution of calcium within the muscle fiber, thereby diminishing
the response to tetanic stimulation. It also decreases the excitability of the motor end-plate
region, reducing the responses to repetitive nerve stimulation and to acetylcholine.

Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical
significance (possible signs and symptoms in parentheses where appropriate)—not
necessarily inclusive:

Those indicating need for medical attention

Incidence more frequent

Gastrointestinal disturbances (abdominal or stomach cramps or pain; diarrhea; nausea;

vomiting){02}

Note: Symptoms of gastrointestinal disturbances, such as nausea and vomiting, may be

related to central nervous system (CNS) effects of quinine .

Incidence less frequent

Blood dyscrasias such as agranulocytosis, leukopenia, and/or

thrombocytopenia (black, tarry stools; blood in urine or stools; cough or hoarseness; fever
or chills; lower back or side pain; painful or difficult urination; pinpoint red spots on skin; sore
throat; unusual bleeding or bruising; unusual tiredness or weakness)

hypoglycemia (anxiety; behavior change, similar to drunkenness; blurred vision; cold

sweats; confusion; convulsions or coma; cool pale skin; difficulty in concentrating;
drowsiness; excessive hunger; fast heartbeat; headache; nausea; nervousness; nightmares;
restless sleep; shakiness; slurred speech; unusual tiredness or weakness)

Note: Hypoglycemia, which may be severe and recurrent, has been reported in some
patients with severe malaria caused by Plasmodium falciparum who received quinine
therapy, and there was some evidence that quinine-induced insulin secretion may have
been one of several possible precipitating factors .

Incidence rare

Cinchonism (abdominal pain; blurred vision; change in color vision; diarrhea; headache;
nausea; ringing or buzzing in ears; vomiting)

hemolytic uremic syndrome (abdominal pain; bruising; fever or chills; increased sweating;
muscle aches; nausea; vomiting)

hypersensitivity reactions (abdominal pain; difficulty in breathing and/or swallowing; fever;

hives; nausea; reddening of the skin, especially around ears; swelling of eyes, face, or inside
of nose; unusual tiredness or weakness)
hypoprothrombinemia (unusual bleeding or bruising)

visual disturbances (blurred vision; disturbed color perception; double vision; night
blindness)

Note: Hemolytic uremic syndrome (HUS) is a multi-system disorder that is characterized by

hemolytic anemia, thrombocytopenia, disseminated intravascular coagulation (DIC), and
acute renal failure . This reaction may occur within hours of a single ingestion of
quinine .Several case reports have been published describing patients who have had an
acute hypersensitivity reaction to quinine that resulted in adult HUS .
Hypoprothrombinemia may be reversed with vitamin K administration

Nursing: Physical Assessment/Monitoring

Assess allergy history prior to beginning therapy. Use caution in presence of cardiac
arrhythmias (quinine has quinidine-like activity) and myasthenia gravis. Assess potential for
interactions with other pharmacological agents patient may be taking (eg, increased or
decreased level/effects and toxicity [digoxin, beta-blockers, warfarin, oxycodone, lidocaine,
etc]). Evaluate therapeutic effectiveness (according to purpose for therapy) and adverse
reactions (monitor for cinchonism with larger doses or long-term therapy). Teach patient
appropriate use, possible side effects/interventions, and adverse symptoms to report.