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Quinine Tablets & Injections - Uses, Dose, Side effects

Quinine is an anti-parasitic medicine that is used to treat malaria and babesiosis. It is derived from the bark of a tree called cinchona.

Quinine Uses:

Treatment of uncomplicated malaria due to Plasmodium falciparum:
- Along with other antimalarial medications, it is used to treat mild cases of P. falciparum malaria that is resistant to chloroquine.
Off-label Use in adults:
- Babesiosis
- Treatment for Plasmodium vivax-caused, simple malaria.

Quinine Dose in Adults

Note:

As different products can contain different amounts of quinine.
For example, one capsule of Qualaquin contains 324 mg of quinine sulfate, which equals 269 mg of the active ingredient.
In Canada, products may contain either 200 mg or 300 mg of quinine sulfate, which equals 167 mg or 250 mg of the active ingredient, respectively.

Quinine for the treatment of uncomplicated chloroquine-resistant P. falciparum Malaria:

The dosage of quinine is different according to guidelines.

In the US, the Centers for Disease Control and Prevention (CDC) suggest taking 648 mg of quinine every 8 hours, usually combined with other medications like doxycycline, tetracycline, or clindamycin (preferred during pregnancy). You'd usually take quinine for 3 days, but if you got infected in Southeast Asia, treatment might last for 7 days.
In Canada, the recommended dose is 600 mg of quinine every 8 hours for 3 to 7 days, usually alongside tetracycline, doxycycline, or clindamycin.

Quinine for treating uncomplicated chloroquine-resistant P. vivax Malaria:

The recommended dosage of quinine is 648 mg every 8 hours taken orally.
This is usually combined with either doxycycline or tetracycline, along with primaquine.
For pregnant patients, an alternative regimen using quinine with clindamycin is suggested.

Note: Typically, quinine is taken for 3 days, but if the infection was acquired in Southeast Asia, treatment might last for 7 days. The duration of the accompanying medication is usually 7 days for doxycycline, tetracycline, or clindamycin, and 14 days for primaquine, regardless of where the infection was acquired.

Quinine for the treatment of Babesiosis (off-label):

The recommended oral dosage is 650 mg taken every 6 to 8 hours for at least 7 to 10 days, typically alongside clindamycin.
If there's a relapse, therapy may need to continue for at least 6 weeks.

Note:

In the US, quinine sulfate capsules are usually 324 mg each, so for adult dosing, two capsules (648 mg quinine sulfate) are typically taken.

Quinine dose in children:

Quinine dose in the treatment of Malaria:

Children and Adolescents (regardless of HIV status):

Limited data available for those under 16 years old.
Duration of quinine treatment depends on the geographic region or type of malaria parasite.
Some smaller patients may face limitations due to the lack of suitable quinine dosage forms.
Uncomplicated Malaria caused by P. falciparum (chloroquine resistant):
- Oral dosage: 10 mg/kg/dose of quinine sulfate every 8 hours for 3 to 7 days, depending on the region.
- Maximum dose per dose: 650 mg.
- Use in combination with tetracycline, doxycycline, or clindamycin (depending on patient age).
Uncomplicated Malaria caused by P. vivax (chloroquine resistant):
- Oral dosage: 10 mg/kg/dose of quinine sulfate every 8 hours for 3 to 7 days, depending on the region.
- Maximum dose per dose: 650 mg.
- Use in combination with primaquine and tetracycline or doxycycline (depending on patient age).
Severe Malaria:
- Oral quinine can be used following IV quinidine, using the regimens mentioned above (dose and duration).
- This treatment may commence once parasite density is less than 1% and the patient can tolerate oral medications.

Quinine for the treatment of Babesiosis:

Children and Adolescents:

Oral dosage: 10 mg/kg/dose of quinine sulfate every 8 hours for 7 to 10 days.
Maximum dose per dose: 650 mg.
Use in combination with clindamycin as a first-line treatment option.

Quinine dose in pregnancy and lactation: C

Quinine crosses the placenta from the mother to the fetus, but the amount reaching the baby is not enough to be considered helpful.
However, using quinine in doses to treat malaria during pregnancy hasn't shown an increased risk of harm to the baby.
Still, it can lead to low blood sugar levels in the mother and other side effects like dizziness, nausea, ringing in the ears, and vomiting.
Malaria itself poses risks to both the mother and the baby, with pregnant women at higher risk of severe infection compared to non-pregnant women.
To prevent malaria, pregnant women should take precautions against mosquito bites when traveling to affected areas.
Quinine may be used to treat malaria during pregnancy, but it's important to follow the latest CDC guidelines.
Additionally, men taking quinine might experience decreased sperm movement and abnormal sperm shape.

Use during breastfeeding:

Quinine can pass into breast milk, but the amount received by breastfeeding infants is very small, estimated to be less than 0.4% of the mother's dose.
When deciding whether to breastfeed during quinine therapy, it's essential to weigh the risks of infant exposure against the benefits of breastfeeding and the need for treatment for the mother.
The World Health Organization (WHO) considers quinine compatible with breastfeeding.
However, infants, especially premature ones or those younger than one month, should be monitored for conditions like hemolysis and jaundice.
Breastfeeding should be avoided during maternal quinine therapy in infants with G6PD deficiency.

Quinine Dose adjustment in renal disease:

For individuals with mild or moderate impairment, there are no specific dosage adjustments provided in the manufacturer's labeling due to lack of studies. However, caution should be exercised when using quinine in these cases.

For those with severe chronic impairment:

In the US, for patients not on dialysis, the initial dose is 648 mg followed by 324 mg every 12 hours.
In Canada, the initial dose is 600 mg followed by 300 mg every 12 hours for 7 days.

Alternative recommendations include:

For those with a glomerular filtration rate (GFR) above 50 mL/minute, no dosage adjustment is necessary.
For glomerular filtration rate (GFR) between 10 to 50 mL/minute, administer every 8 to 12 hours.
For glomerular filtration rate (GFR) below 10 mL/minute, administer every 24 hours.
For intermittent hemodialysis, administer the dose after dialysis, with around 6.5% clearance achieved within 1 hour of hemodialysis.
For peritoneal dialysis, dose as for GFR below 10 mL/minute.
For continuous renal replacement therapy (CRRT), dose as for GFR between 10 to 50 mL/minute.

Quinine Dose adjustment in liver disease:

For individuals with mild to moderate hepatic impairment, which corresponds to Child-Pugh classes A and B, no adjustment in dosing is typically needed. However, it's crucial to monitor them closely during treatment.
In cases of severe hepatic impairment, corresponding to Child-Pugh class C, it's best to avoid using quinine altogether.

Side effects of Quinine:

Cardiovascular:
- Appearance Of U Waves On ECG
- Atrial Fibrillation
- Atrioventricular Block
- Bradycardia
- Cardiac Arrhythmia
- Chest Pain
- Flushing
- Hypersensitivity Angiitis
- Hypotension
- Nodal Rhythm Disorder (Nodal Escape Beats)
- Orthostatic Hypotension
- Palpitations
- Prolonged QT Interval On ECG
- Syncope
- Tachycardia
- Torsades De Pointes
- Unifocal Premature Ventricular Contractions
- Vasodilation
- Ventricular Fibrillation
- Ventricular Tachycardia
Central Nervous System:
- Altered Mental Status
- Aphasia
- Ataxia
- Chills
- Coma
- Confusion
- Disorientation
- Dizziness
- Dystonic Reaction
- Headache
- Restlessness
- Seizure
- Vertigo
Dermatologic:
- Allergic Contact Dermatitis
- Bullous Dermatitis
- Diaphoresis
- Exfoliative Dermatitis
- Erythema Multiforme
- Pruritus
- Skin Necrosis (Acral)
- Skin Photosensitivity
- Skin Rash (Papular Rash
- Scarlatiniform Rash
- Urticaria)
- Stevens-Johnson Syndrome
- Toxic Epidermal Necrolysis
Endocrine & Metabolic:
- Hypoglycemia
Gastrointestinal:
- Abdominal Pain
- Anorexia
- Diarrhea
- Esophagitis
- Gastric Irritation
- Nausea
- Vomiting
Genitourinary:
- Hemoglobinuria
Hematologic & Oncologic:
- Agranulocytosis
- Aplastic Anemia
- Blood Coagulation Disorder
- Bruise
- Disseminated Intravascular Coagulation
- Hemolysis (Blackwater Fever)
- Hemolytic Anemia
- Hemolytic-Uremic Syndrome
- Hemorrhage
- Hypoprothrombinemia
- Immune Thrombocytopenia (ITP)
- Leukopenia
- Neutropenia
- Pancytopenia
- Petechia
- Thrombocytopenia
- Thrombotic Thrombocytopenic Purpura
Hepatic:
- Abnormal Hepatic Function Tests
- Granulomatous Hepatitis
- Hepatitis
- Jaundice
Hypersensitivity:
- Hypersensitivity Reaction
Immunologic:
- Antibody Development (Lupus Anticoagulant Syndrome)
Neuromuscular & Skeletal:
- Lupus-Like Syndrome
- Myalgia
- Tremor
- Weakness
Ophthalmic:
- Blindness
- Blurred Vision (With Or Without Scotomata)
- Diplopia
- Mydriasis
- Nocturnal Amblyopia
- Optic Neuritis
- Photophobia
- Vision Color Changes
- Vision Loss (Sudden)
- Visual Field Loss
Otic:
- Auditory Impairment
- Deafness
- Tinnitus
Renal:
- Acute Interstitial Nephritis
- Renal Failure
- Renal Insufficiency
Respiratory:
- Asthma
- Dyspnea
- Pulmonary Edema
Miscellaneous:
- Fever

Contraindications to Quinine:

If you've had a bad reaction to quinine before or are allergic to it or any parts of the medicine, or if you've had a reaction to mefloquine or quinidine (because they're similar), it's not safe to take quinine.
Also, if you've had certain serious reactions in the past like blackwater fever, immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, or if you have certain conditions like prolonged QT interval, myasthenia gravis, or optic neuritis, quinine might not be right for you.

Warnings and precautions

Hemolytic anemia

Some people have experienced sudden hemolytic anemia while taking quinine, especially those with G6PD deficiency, although it's not certain if quinine directly causes this.
While using quinine, it's important to keep an eye on your hemoglobin and hematocrit levels, which can indicate if your red blood cells are breaking down too quickly.
If hemolytic anemia occurs, it's crucial to stop taking quinine.

Hypersensitivity reactions

Quinine can sometimes cause severe allergic reactions like Stevens-Johnson syndrome or anaphylactic shock.
If you notice any signs of being sensitive to quinine, it's important to stop taking it right away.
Other issues like acute interstitial nephritis, neutropenia, or granulomatous hepatitis might also happen due to hypersensitivity reactions.

Hypoglycemia:

Using quinine might lead to significant drops in blood sugar levels, known as hypoglycemia, because quinine can prompt the release of insulin in the body.

Thrombocytopenia:

Using quinine can sometimes lead to low platelet counts, a condition called thrombocytopenia.
In some cases, this can be caused by the body's immune system attacking platelets, which can be severe and life-threatening.
Additionally, chronic kidney failure linked to thrombotic thrombocytopenic purpura (TTP) has been reported.
Generally, thrombocytopenia gets better within about a week after stopping quinine.
However, if you're exposed to quinine again, thrombocytopenia might become more severe and happen more quickly.

Modified cardiac conduction

Quinine can affect the way your heart beats, so it's important to be cautious if you have conditions like atrial fibrillation or flutter, as it might actually increase your heart rate.
It's also important to use caution if you have any conditions that could make your heart's QT interval longer or cause irregular heart rhythms.
Quinine has been linked to prolonging the QT interval, which can sometimes lead to serious heart problems like torsade de pointes or ventricular fibrillation, which can be fatal.
It's not recommended to use quinine if you already have a long QT interval.
Also, it's best to avoid taking quinine with certain other medications that can prolong the QT interval, like certain antiarrhythmic drugs.
Additionally, quinine can lengthen the PR and QRS intervals in a concentration-dependent manner, especially in patients with existing heart conditions or those taking other medications that affect these intervals.

Hepatic impairment:

Quinine should be used carefully in patients with mild to moderate liver problems.
However, it's best to avoid using it altogether in patients with severe liver impairment.

Renal impairment:

In individuals with kidney problems, it's important to use quinine cautiously.
If someone has severe chronic kidney issues, adjusting the dosage of quinine is recommended.

Quinine: Drug Interaction

Risk Factor C (Monitor therapy)
Alkalinizing Agents	May raise the level of quinine in the serum.
Androgens	Can make blood glucose lowering medications more effective at lowering blood sugar. Danazol is an exception.
Antidiabetic Agents	Possibly makes hypoglycemia-associated agents more effective.
Antipsychotic Agents (Phenothiazines)	Antipsychotic Agents' serum concentration may rise in response to antimalarial drugs (Phenothiazines).
Aprepitant	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Blood Pressure Lowering Agents	Blood pressure lowering agents' hypotensive effects may be enhanced by herbs (Hypotensive Properties).
Bosentan	May lower the serum level of CYP3A4 substrates (High risk with Inducers).
Brentuximab Vedotin	The serum concentration of Brentuximab Vedotin may rise in response to P-glycoprotein/ABCB1 Inhibitors. More specifically, levels of the substance's active monomethyl auristatin E (MMAE) component might rise.
Celiprolol	Celiprolol's serum levels may rise in response to P-glycoprotein/ABCB1 inhibitors.
CYP2D6 Substrates (High risk with Inhibitors)	The serum concentration of CYP2D6 Substrates may rise in response to quinine (High risk with Inhibitors).
CYP3A4 Inducers (Moderate)	May lower the serum level of CYP3A4 substrates (High risk with Inducers).
CYP3A4 Inhibitors (Moderate)	May slow down CYP3A4 substrate metabolism (High risk with Inhibitors).
Deferasirox	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Digoxin	QuiNINE may increase the serum concentration of Digoxin.
Duvelisib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Erdafitinib	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Erdafitinib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Erdafitinib	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Everolimus	P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Everolimus.
Fingolimod	May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias (including TdP) with a continuous overnight ECG when fingolimod is combined with QT prolonging drugs. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Fosaprepitant	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Fosnetupitant	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Herbs (Hypoglycemic Properties	May intensify the hypoglycemic effects of agents associated with hypoglycemia.
Herbs (Hypotensive Properties)	Could intensify the negative or poisonous effects of other herbs (Hypotensive Properties). There could be signs of excessive blood pressure dropping.
Hypoglycemia-Associated Agents	May increase other hypoglycemia-associated agents' hypoglycemic effects.
Larotrectinib	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Larotrectinib	P-glycoprotein/ABCB1 Inhibitors may raise larotrectinib's serum levels.
Local Anesthetics	The harmful or toxic effects of local anaesthetics may be increased by methemoglobinemia associated agents. In particular, there may be an elevated risk for methemoglobinemia.
Maitake	May enhance the hypoglycemic effect of Blood Glucose Lowering Agents.
Monoamine Oxidase Inhibitors	May enhance the hypoglycemic effect of Blood Glucose Lowering Agents.
Naldemedine	The serum concentration of Naldemedine may rise in response to P-glycoprotein/ABCB1 Inhibitors.
Naloxegol	The quantity of Naloxegol in the serum may rise in response to P-glycoprotein/ABCB1 inhibitors.
Netupitant	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Nevirapine	May lower the level of quinine in the serum.
Nitric Oxide	May intensify the harmful/toxic effects of agents associated with methemoglobinemia. Combinations of these medications may make substantial methemoglobinemia more likely. When nitric oxide is administered along with other medications known to cause the development of methemoglobinemia, patients should be watched closely for symptoms (such as hypoxia and cyanosis). Do not use lidocaine or prilocaine.
Palbociclib	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Pegvisomant	May enhance the hypoglycemic effect of Blood Glucose Lowering Agents.
P-glycoprotein/ABCB1 Inhibitors	May increase the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of pglycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
P-glycoprotein/ABCB1 Substrates	P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Exceptions: Loperamide.
Prilocaine	The harmful or toxic effects of Prilocaine may be increased by methemoglobinemia associated agents. Combinations of these medications may make substantial methemoglobinemia more likely. Monitoring patients for methemoglobinemia symptoms (such as hypoxia and cyanosis) is necessary when prilocaine is used with other medications that can cause methemoglobinemia in patients. When giving these medicines to newborns, avoid using lidocaine or prilocaine.
Prothionamide	Can make blood glucose lowering medications more effective at lowering blood sugar.
Prucalopride	P-glycoprotein/ABCB1 Prucalopride's serum levels may rise in the presence of inhibitors.
QT-prolonging Agents (Indeterminate Risk - Avoid)	May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk.
QT-prolonging Agents (Indeterminate Risk - Caution)	May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Quinolones	Can make blood glucose lowering medications more effective at lowering blood sugar. Blood Glucose Lowering Agents' therapeutic impact may be lessened by quinolones. In particular, the use of quinolones may result in a loss of blood sugar control if an agent is being used to treat diabetes.
Ranolazine	The serum concentration of ranolazine may rise in response to P-glycoprotein/ABCB1 inhibitors.
Ranolazine	P-glycoprotein/ABCB1 Substrates serum levels can rise.
RifAXIMin	The concentration of RifAXIMin in the serum may rise in response to P-glycoprotein/ABCB1 inhibitors.
Salicylates	Can make blood glucose lowering medications more effective at lowering blood sugar.
Sarilumab	May lower the serum level of CYP3A4 substrates (High risk with Inducers).
Selective Serotonin Reuptake Inhibitors	Can make blood glucose lowering medications more effective at lowering blood sugar.
Silodosin	The serum concentration of Silodosin may rise in response to P-glycoprotein/ABCB1 Inhibitors.
Siltuximab	May lower the serum level of CYP3A4 substrates (High risk with Inducers).
Simeprevir	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Sodium Nitrite	Methemoglobinemia Associated Agents might make sodium nitrite more harmful or hazardous. Combinations of these medications may make substantial methemoglobinemia more likely.
Talazoparib	The serum concentration of Talazoparib may rise in response to P-glycoprotein/ABCB1 inhibitors. Management: Separate interaction monographs are written in-depth for each of the above exceptions.
Tegaserod	Tegaserod's serum levels may rise in response to P-glycoprotein/ABCB1 inhibitors.
Tetracycline (Systemic)	May raise the level of quinine in the serum.
Theophylline Derivatives	Theophylline derivatives' serum levels may be elevated by quinine.
Tobacco (Smoked)	May lower the level of quinine in the serum.
Tocilizumab	May lower the serum level of CYP3A4 substrates (High risk with Inducers).
Vitamin K Antagonists (eg, warfarin)	The anticoagulant impact of vitamin K antagonists may be strengthened by quinine.
Risk Factor D (Consider therapy modification)
Afatinib	P-glycoprotein/ABCB1 Inhibitors may raise the level of Afatinib in the serum. Management: If afatinib is poorly tolerated, reduce the dose by 10 mg. Some non-US labelling advises staying away from combinations wherever possible. If using, give the P-gp inhibitor either right away or right after the afatinib dose.
Amiodarone	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of Amiodarone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Amisulpride	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Amisulpride. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities.
Arsenic Trioxide	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of Arsenic Trioxide. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Astemizole	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of Astemizole. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Azithromycin (Systemic)	The QTc-prolonging effect of azithromycin may be enhanced by QT-prolonging agents (Highest Risk) (Systemic). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Bedaquiline	Bedaquiline's ability to prolong QTc may be enhanced by other QT-prolonging substances (highest risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Bepridil	Bepridil's ability to prolong QTc may be strengthened by other QT-prolonging substances (Highest Risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients who have additional QTc prolongation risk factors.
Betrixaban	The serum concentration of betrixaban may rise in response to P-glycoprotein/ABCB1 inhibitors. Treatment: If betrixaban is used with a P-glycoprotein inhibitor, reduce the adult dose to an initial single dose of 80 mg, followed by a dose of 40 mg once day.
Bilastine	The serum concentration of bilastine may rise in response to P-glycoprotein/ABCB1 inhibitors. Management: When possible, look into alternatives; bilastine should be avoided in patients using p-glycoprotein inhibitors who have moderate to severe renal insufficiency.
CarBAMazepine	May lower the level of quinine in the serum. CarBAMazepine's serum levels may rise in response to quinine.
Chloroquine	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Chloroquine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
ChlorproMAZINE	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of ChlorproMAZINE. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Cimetidine	May increase the serum concentration of QuiNINE.
Cisapride	Cisapride's ability to prolong QTc may be strengthened by other QT-prolonging substances (Highest Risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Clofazimine	The QTc-prolonging action of clofazimine may be enhanced by QT-prolonging Agents (Highest Risk). Management: Take into account alternatives to this fusion. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
CloZAPine	The QTc-prolonging action of CloZAPine may be strengthened by QT-prolonging Agents (Highest Risk). Management: Take into account alternatives to this fusion. Patients who have additional risk factors are probably more at risk, such as older age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher medication concentrations.
Colchicine	The serum concentration of colchicine may rise in response to P-glycoprotein/ABCB1 inhibitors. It's possible that colchicine will distribute more widely throughout some tissues, like the brain. Treatment: Patients receiving a p-glycoprotein inhibitor and having compromised renal or hepatic function should not take colchicine. Colchicine dosage should be decreased in patients with normal renal and hepatic function as instructed. For information, see the entire monograph.
CYP3A4 Inducers (Strong)	May speed up CYP3A4 substrate metabolism (High risk with Inducers). Management: Take into account a substitute for one of the interfering medications. Specific contraindications may apply to some combinations. the relevant manufacturer's label.
CYP3A4 Inhibitors (Strong)	May slow down CYP3A4 substrate metabolism (High risk with Inhibitors).
Dabigatran Etexilate	The active metabolite(s) of dabigatran etexilate may be present in higher serum quantities when P-glycoprotein/ABCB1 Inhibitors are used. Reduced doses of dabigatran may be required for treatment. Specific recommendations differ significantly depending on the labelling used in the US versus Canada, the type of P-gp inhibitor used, renal function, and the indication for dabigatran treatment. cite the complete monograph or the dabigatran labelling.
Dabrafenib	May lower the level of CYP3A4 substrates in the serum (High risk with Inducers). Management: When possible, look for CYP3A4 substrate substitutes. Monitor the clinical effects of the substrate carefully if concurrent therapy cannot be avoided (particularly therapeutic effects).
Dapsone (Systemic)	Antimalarial drugs could intensify the harmful or hazardous effects of dapsone (Systemic). In particular, the use of antimalarial medications concurrently with dapsone may raise the risk of hemolytic responses. Dapsone (Systemic) may make antimalarial agents more harmful or poisonous. More specifically, using dapsone at the same time as an antimalarial drug may make hemolytic responses more likely. Treatment: Carefully observe patients for any indications or symptoms of hemolytic responses while administering dapsone and antimalarial medications, especially in those who have haemoglobin M, glucose-6-phosphate dehydrogenase (G6PD),
Dapsone (Topical)	Antimalarial drugs could intensify the harmful or hazardous effects of dapsone (Topical). Particularly, there may be a higher risk of hemolytic responses. Treatment: Apply topical dapsone and antimalarial medications while closely monitoring for hemolytic reactions' signs and symptoms. Patients who lack glucose-6-phosphate dehydrogenase may be especially vulnerable to negative hematologic consequences.
Dasatinib	Dasatinib's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Delamanid	Delamanid's ability to prolong QTc may be enhanced by other QT-prolonging substances (Highest Risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Doxepin-Containing Products	The QTcprolonging action of products containing doxepin may be enhanced by QT-prolonging Agents (Highest Risk). Management: Take into account alternatives to this fusion. Patients with additional risk factors, such as older age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher medication concentrations, are more likely to experience adverse outcomes.
DOXOrubicin (Conventional)	Inhibitors of P-glycoprotein/ABCB1 may raise DOXOrubicin's serum concentration (Conventional). Treatment: Whenever possible, avoid using P-glycoprotein inhibitors in patients receiving doxorubicin. Pfizer Inc., a U.S. manufacturer, advises against using certain mixtures.
Dronedarone	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of Dronedarone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Droperidol	Droperidol's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Edoxaban	The concentration of Edoxaban in the serum may rise in response to P-glycoprotein/ABCB1 inhibitors. Management: For more, see the whole monograph. Patients taking edoxaban for venous thromboembolism in conjunction with specific P-gp inhibitors are advised to take it in lower doses. It is not advised to modify the dosage when using edoxaban for atrial fibrillation.
Encorafenib	Could make QT-prolonging agents' effect on QTc longer (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Enzalutamide	May lower the serum level of CYP3A4 substrates (High risk with Inducers). Management: Enzalutamide should not be used concurrently with CYP3A4 substrates that have a limited therapeutic index. Enzalutamide use, like with the use of any other CYP3A4 substrate, should be done cautiously and under close observation.
Escitalopram	Escitalopram's ability to prolong QTc may be enhanced by QT-prolonging Agents (Highest Risk). Management: Take into account alternatives to this fusion. Patients with additional risk factors, such as older age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher medication concentrations, are more likely to experience adverse outcomes.
Flecainide	Flecainide's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Fluconazole	Fluconazole's ability to prolong QTc may be enhanced by other QT-prolonging substances (highest risk). Fluconazole may increase the QTc-prolonging impact of other QT-prolonging drugs (Highest Risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Fosphenytoin	May lower the level of quinine in the serum.
Gadobenate Dimeglumine	Gadobenate Dimeglumine's ability to prolong QT intervals may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Gemifloxacin	Potentially amplifies the QTc-prolonging effects of other QT-prolonging agents (Highest Risk). Management: Take into account different pharmacological combinations. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Gilteritinib	Could make QT-prolonging agents' effect on QTc longer (Highest Risk). Management: Take into account alternatives to this fusion. If use is required, keep an eye out for arrhythmias and a prolonged QTc interval.
Haloperidol	QT-prolonging Miscellaneous Agents (Highest Risk) may enhance the QTcprolonging effect of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
HMG-CoA Reductase Inhibitors (Statins)	The serum levels of HMG-CoA Reductase Inhibitors may rise when QuiNINE is used (Statins). When taken with quinine, atorvastatin, simvastatin, or lovastatin may be managed by using reduced starting, maintenance, and maximum doses. Exceptions: Red yeast rice, Rosuvastatin, Fluvastatin, Pitavastatin, and Pravastatin.
Inotuzumab Ozogamicin	Inotuzumab ozogamicin may have a greater QTc-prolonging impact when used with QT-prolonging Agents (Highest Risk). Management: Take into account alternatives to this fusion. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Levofloxacin-Containing Products (Systemic)	May increase the QTc-prolonging action of other QT-prolonging agents (Highest Risk). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Lofexidine	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Lofexidine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Lorlatinib	ay lower the serum level of CYP3A4 substrates (High risk with Inducers). Management: Avoid taking lorlatinib at the same time as any CYP3A4 substrates for which even a small drop in serum levels of the substrate could result in therapeutic failure and negative clinical outcomes.
Methadone	Potentially amplifies the QTc-prolonging effects of other QT-prolonging agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Midostaurin	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Midostaurin. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
MiFEPRIStone	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors). Management: During and two weeks after mifepristone treatment, reduce doses of CYP3A4 substrates and keep an eye out for elevated amounts or toxicity. Fentanyl, pimozide, quinidine, sirolimus, and tacrolimus should all be avoided. Cyclosporine should also be avoided.
Mitotane	May lower the serum level of CYP3A4 substrates (High risk with Inducers). Treatment: When administered in individuals receiving mitotane, doses of CYP3A4 substrates may need to be significantly modified.
OLANZapine	OLANZapine's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Ondansetron	Ondansetron's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Osimertinib	Osimertinib's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Pentamidine (Systemic)	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pentamidine (Systemic). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
PHENobarbital	PHENobarbital's serum levels may be elevated by quinine. PHENobarbital may lower the level of quinine in the blood.
Phenytoin	May lower the level of quinine in the serum.
Pilsicainide	Pilsicainide's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. If combined, keep an eye out for cardiac arrhythmias and a prolonged QTc interval. Patients may be considerably more at risk for QTc prolongation if they have additional risk factors.
Propafenone	May enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
QT-prolonging Class IA Antiarrhythmics (Highest Risk)	May enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
QT-prolonging Class III Antiarrhythmics (Highest Risk)	May enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Dronedarone.
QT-prolonging Kinase Inhibitors (Highest Risk)	May enhance the QTc-prolonging effect of QTprolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
QT-prolonging Miscellaneous Agents (Highest Risk)	May enhance the QTc-prolonging effect of QuiNINE. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Arsenic Trioxide; Astemizole; Bedaquiline; Bepridil; ChlorproMAZINE; Cisapride; Delamanid.
QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk)	May enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase the serum concentration of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Fluconazole; Nilotinib; Ribociclib.
RisperiDONE	QT-prolonging Agents (Highest Risk) may enhance the CNS depressant effect of RisperiDONE. QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of RisperiDONE. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
Sodium Stibogluconate	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Sodium Stibogluconate. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk.
St John's Wort	May lower the serum level of CYP3A4 substrates (High risk with Inducers). Management: Take into account a substitute for one of the interfering medications. Specific contraindications may apply to some combinations. the relevant manufacturer's label.
Stiripentol	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors). Management: Due to the increased potential for side effects and toxicity, stiripentol should not be used with CYP3A4 substrates that are thought to have a narrow therapeutic index. Use of stiripentol with any CYP3A4 substrate necessitates closer observation.
Telithromycin	May intensify QuiNINE's QTc-prolonging effects. The serum concentration of QuiNINE may rise in response to telithromycin. Treatment: If at all feasible, avoid concurrent therapy with quinine and telithromycin due to the risk of higher quinine serum levels and potential cardiac side effects.
Vemurafenib	QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Vemurafenib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities.
Venetoclax	Venetoclax serum levels may rise in response to P-glycoprotein/ABCB1 inhibitors. In patients who need concurrent treatment with P-glycoprotein (P-gp) inhibitors, consider reducing the dose of venetoclax by at least 50%.
Risk Factor X (Avoid combination)
Antacids	May lower the level of quinine in the serum. Calcium carbonate, potassium bicarbonate, and sodium bicarbonate are exceptions.
Antihepaciviral Combination Products	May raise the level of quinine in the serum.
Artemether	Could intensify the negative or hazardous effects of antimalarial drugs. Management: Unless there are no other treatment options available, artemether/lumefantrine (combination product) should not be used with other antimalarials.
Citalopram	Citalopram's ability to prolong QTc may be enhanced by QT-prolonging Agents (Highest Risk).
Clarithromycin	Clarithromycin's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk).
Conivaptan	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Domperidone	The QTc-prolonging action of Domperidone may be strengthened by QT-prolonging Agents (Highest Risk).
Entrectinib	Could make QT-prolonging agents' effect on QTc longer (Highest Risk).
Flupentixol	Flupentixol's ability to prolong QTc may be enhanced by QT-prolonging Agents (Highest Risk).
Fusidic Acid (Systemic)	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Halofantrine	May intensify QuiNINE's QTc-prolonging effects.
Idelalisib	May elevate CYP3A4 substrates' serum concentration (High risk with Inhibitors).
Lefamulin	Could intensify the QTc-prolonging effects of CYP3A4 substrates. Management: Avoid taking lefamulin pills with CYP3A4 substrates that prolong QT. The prescribing label for lefamulin states that this combination is not recommended.
Lopinavir	May lower the level of quinine in the serum. Lopinavir/ritonavir has been associated with this outcome. It's unknown how much lopinavir and ritonavir individually contributed to this outcome.
Lumefantrine	Antimalarial drugs may intensify Lumefantrine's harmful or toxic effects. Management: Unless there are no other treatment options available, artemether/lumefantrine (combination product) should not be used with other antimalarials.
Mefloquine	Mefloquine's negative/toxic effects could be exacerbated by quinine. Particularly, there may be an increased risk for QTc-prolongation and convulsions. The serum concentration of QuiNINE may rise in response to mefloquine. Management: When possible, avoid taking two medications at the same time and postpone giving mefloquine until at least 12 hours have passed since the last dosage of quinine.
Moxifloxacin (Systemic)	Moxifloxacin's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk) (Systemic).
Neuromuscular-Blocking Agents	The neuromuscular-blocking effects of neuromuscular-blocking agents may be strengthened by quinine.
Nilotinib	The QTc-prolonging action of nilotinib may be strengthened by QT-prolonging agents (Highest Risk).
PAZOPanib	The serum concentration of PAZOPanib may rise in response to P-glycoprotein/ABCB1 inhibitors.
Pimozide	The QTc-prolonging action of pimozide may be strengthened by QT-prolonging agents (Highest Risk). Management: Take into account alternatives to this fusion. These toxicities are probably more likely to occur in patients who have additional risk factors, such as advanced age, female sex, bradycardia, hypokalemia, hypomagnesemia, cardiac disease, and higher drug concentrations.
Piperaquine	The QTc-prolonging action of piperaquine may be enhanced by QT-prolonging Agents (Highest Risk).
Posaconazole	May raise the serum level of CYP3A4 substrates that prolong QT. The risk of proarrhythmic effects and other comparable toxicities may increase as a result of such increases.
Probucol	Probucol's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk).
QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk)	Potentially amplifies the QTc-prolonging effects of other QT-prolonging agents (Highest Risk). The serum concentration of QT-prolonging Miscellaneous Agents may rise in response to QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk) (Highest Risk). For example, clarithromycin.
QUEtiapine	The QTc-prolonging effect of quetiapine may be enhanced by QT-prolonging agents (Highest Risk).
Ribociclib	The QTc-prolonging action of ribociclib may be strengthened by QT-prolonging Agents (Highest Risk).
RifAMPin	May lower the level of quinine in the serum.
Ritonavir	May lower the level of quinine in the serum. Lopinavir/ritonavir has been associated with this outcome. It's unknown how much lopinavir and ritonavir individually contributed to this outcome. Ritonavir's serum levels might be raised by quinine. Ritonavir may raise the level of quinine in the blood.
Sparfloxacin	The QTc-prolonging effect of sparfloxacin may be enhanced by QT-prolonging agents (Highest Risk).
Thioridazine	Thioridazine's ability to prolong QTc may be enhanced by QT-prolonging agents (Highest Risk).
Topotecan	The serum concentration of topotecan may rise in response to P-glycoprotein/ABCB1 inhibitors.
VinCRIStine (Liposomal)	The serum concentration of VinCRIStine may rise in response to P-glycoprotein/ABCB1 Inhibitors (Liposomal).

Monitoring parameters:

Complete Blood Count (CBC) with Platelet Count:
- Keep track of blood cell counts, including platelets, to ensure they stay within a healthy range.
Liver Function Tests:
- Regularly check liver function to make sure the liver is working properly.
Blood Glucose:
- Monitor blood sugar levels regularly, especially since quinine can cause significant drops in glucose levels.
Electrocardiogram (ECG):
- Perform ECG tests to monitor heart rhythm and detect any abnormalities, as quinine can affect cardiac conduction.
Ophthalmologic Examination:
- Conduct regular eye exams to check for any changes in vision or signs of optic nerve issues.

How to administer Quinine?

Guidelines for Taking Quinine:

Avoid Aluminum- or Magnesium-Containing Antacids:
- Don't take quinine with antacids containing aluminum or magnesium, as they can interfere with how quinine is absorbed by the body.
Swallow Whole:
- Take the dose whole without breaking or crushing it to prevent experiencing the bitter taste of quinine.
May be Administered with Food:
- You can take quinine with food if needed.

Mechanism of action of Quinine:

Quinine slows down how the body uses oxygen and processes carbohydrates.
It also inserts itself into the DNA of the parasite, messing up its ability to make copies of itself and carry out important genetic functions.
This is how it stops the parasite from growing and spreading in the body.
Additionally, it has effects on the heart and blood vessels that are similar to another medication called quinidine.

Absorption:

Readily absorbed, primarily from the upper small intestine.

Distribution:

In children with malaria: ~0.9 L/kg
In adults: 2.5 to 7.1 L/kg, varies with infection severity.
Intraerythrocytic levels: ~30% to 50% of plasma concentration.
Poor distribution to cerebrospinal fluid (CSF): ~2% to 7% of plasma concentration.

Protein Binding:

69% to 92% in healthy subjects, increased to 78% to 95% with malaria due to increased alpha 1-acid glycoprotein.

Metabolism:

Primarily hepatic via CYP450 enzymes, mainly CYP3A4.
Forms metabolites, with the major metabolite, 3-hydroxyquinine, being less active than the parent compound.

Bioavailability:

76% to 88% in healthy subjects, increased with malaria.

Half-life Elimination:

In children: ~3 hours in healthy subjects, ~12 hours with malaria.
In healthy adults: 10 to 13 hours.
In healthy elderly subjects: 18 hours.

Time to Peak, Serum:

In children: 2 hours in healthy subjects, 4 hours with malaria.
In adults: 2 to 4 hours in healthy subjects, 1 to 11 hours with malaria.

Excretion:

Primarily via urine (~20% as unchanged drug), with renal excretion doubling in acidic urine conditions.

Quinine Brand Names (International):

Qualaquin
APO-QuiNINE
JAMP-QuiNINE
PRO-QuiNINE-200
QuiNINE-Odan
TEVA-QuiNINE
Aethylcarbonis Chinin
Albiquin
Circonyl
Genin
Jasoquin
Kanaquine
Kinin
Malaquin
Q200
Q300
Quinate
Quinbisu
Quinimax
Quininga

Quinine Brand Names in Pakistan:

Quinine 300 mg/ml Injection
Gomal	Lahore Chemical & Pharmaceutical Works (Pvt) Ltd
Hydroquine	Pharmedic (Pvt) Ltd.
Konien	Multinational Buisness Link
Malapak	Medicraft Pharmaceuticals (Pvt) Ltd.
Q-Phos	Caraway Pharmaceuticals
Quinine	Lawrence Pharma
Quinine Dihydrochloride	Orient Laboratories
Quinine Dihydrochloride	Venus Pharma
Zafquin	Zafa Pharmaceutical Laboratories (Pvt) Ltd.

Quinine 300 mg Tablets
Circonyl	Rotex Medica Pakistan (Pvt) Ltd
Mediquin	Semos Pharmaceuticals (Pvt) Ltd.
Pmalamed	Medicraft Pharmaceuticals (Pvt) Ltd.
Quinine Bi-Sulphate	Lahore Chemical & Pharmaceutical Works (Pvt) Ltd

Quinine Tablets & Injections - Uses, Dose, Side effects

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