Drugs List

Therapeutic Indications

Uses

Cramps in legs - nocturnal
Treatment of chloroquine resistant malaria

Treatment of chloroquine-resistant malaria.

Prevention / relief of nocturnal leg cramps in adults and the elderly, when cramps cause regular disruption to sleep.

For up to date advice on geographical resistance patterns and appropriate prophylaxis, current guidelines should be consulted.
Guidelines for Malaria Prevention from the Health Protection Agency specifically developed for travellers from the United Kingdom may be obtained from the Public Health England website:https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellers-from-the-uk

Contraindications

Haemoglobinuria
Long QT syndrome
Myasthenia gravis
Optic neuritis
Tinnitus
Torsade de pointes

Precautions and Warnings

Family history of long QT syndrome
Atrial fibrillation
Atrioventricular block
Breastfeeding
Cardiac conduction defects
Electrolyte imbalance
G6PD deficiency
Glucose-galactose malabsorption syndrome
Hepatic impairment
Hereditary fructose intolerance
History of torsade de pointes
Pregnancy
Renal impairment
Severe cardiac disorder

Correct electrolyte disorders before treatment
Reduce dose and/or alter dose interval in patients with hepatic impairment
Reduce dose and/or alter dose interval in patients with renal impairment
Advice available from specialist unit for the use of this drug
Advise ability to drive/operate machinery may be affected by side effects
Before initiating therapy enquire about previous hypersensitivity reactions
Some formulations contain sucrose
Consider monitoring ECG in patients at risk of QT prolongation
In treatment of night cramps, reassess need for therapy every 3 months
Monitor serum electrolytes
Advise patient to report unexplained fever, sore throat, bruising, bleeding
Discontinue if severe hypersensitivity reactions occur
Discontinue, in treatment of night cramps, if symptoms of cinchonism occur

Quinine should be used with caution in patients with atrial fibrillation or other serious heart disease as it may cause hypoprothrombinaemia.

Use with caution in patients with glucose-6-phosphate dehydrogenase deficiency as there may be a risk of haemolysis in these patients.

Patients who have previously experienced adverse reactions to quinine including that in tonic water or other beverages should not be prescribed quinine.

Pregnancy and Lactation

Pregnancy

Quinine should be used with caution in pregnancy.

Quinine should be used only for the treatment of chloroquine-resistant malaria as the potential risk to the foetus due to treatment is much less than risks due to severe disease. Pregnant women treated with quinine are at risk of hypoglycaemia caused or exacerbated by quinine-induced hyperinsulinaemia.

High doses of quinine have been used to attempt induction of abortion and may cause congenital abnormalities of the CNS and extremities, and high doses have been associated with deafness and photosensitivity in the neonate. However, standard malaria treatment doses are considered to be safe in pregnancy.

Quinine is contraindicated in the treatment of nocturnal leg cramps during pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Quinine should be used with caution in breastfeeding.

Quinine is excreted in human breast milk. There is a potential risk of thrombocytopenia in neonates. Therefore quinine should only be used in breastfeeding if the benefits outweighs the risks.

Newborns at risk of glucose-6-phosphate dehydrogenase deficiency should not be breastfed until this disease can be ruled out.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Abortion
Acute renal failure
Agitation
Agranulocytosis
Altered colour perception
Angioedema
AV conduction disorders
Blindness
Blood disorders
Blurred vision
Bronchospasm
Cardiotoxicity
Cardiovascular effects
Cinchonism
Circulatory failure
CNS disturbances
Coma
Confusion
Decrease in blood pressure
Diarrhoea
Dyspnoea
Eczematous reactions
Erythema
Exacerbation of myasthenia gravis
Excitement
Fever
Gastro-intestinal disturbances
Haemoglobinuria
Haemolysis
Haemolytic uraemic syndrome
Headache
Hearing disturbances
Hot and flushed skin
Hypersensitivity reactions
Hypoglycaemia
Hypoprothrombinaemia
Intravascular coagulation
Lichen planus
Muscle weakness
Nausea
Oedema
Oliguria
Pancytopenia
Photosensitivity
Prolongation of QT interval
Pruritus
Rash
Renal impairment
T-wave changes
Thrombocytopenia
Thrombocytopenic purpura
Tinnitus
Unconsciousness
Urticaria
Vertigo
Visual disturbances
Visual field defects
Vomiting
Weak pulse
Widened QRS complex

Presentation

Oral formulations of quinine sulfate

Drugs List

Therapeutic Indications

Uses

Cramps in legs - nocturnal
Treatment of chloroquine resistant malaria

Treatment of chloroquine-resistant malaria.

Prevention / relief of nocturnal leg cramps in adults and the elderly, when cramps cause regular disruption to sleep.

For up to date advice on geographical resistance patterns and appropriate prophylaxis, current guidelines should be consulted.
Guidelines for Malaria Prevention from the Health Protection Agency specifically developed for travellers from the United Kingdom may be obtained from the Public Health England website:https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellers-from-the-uk

Dosage

If quinine resistance is known or suspected in the patient then supplementary treatment with an additional antimalarial is recommended.

Adults

Elderly

Children

Patients with Renal Impairment

Additional Dosage Information

Contraindications

Haemoglobinuria
Long QT syndrome
Myasthenia gravis
Optic neuritis
Tinnitus
Torsade de pointes

Precautions and Warnings

Family history of long QT syndrome
Atrial fibrillation
Atrioventricular block
Breastfeeding
Cardiac conduction defects
Electrolyte imbalance
G6PD deficiency
Glucose-galactose malabsorption syndrome
Hepatic impairment
Hereditary fructose intolerance
History of torsade de pointes
Pregnancy
Renal impairment
Severe cardiac disorder

Correct electrolyte disorders before treatment
Reduce dose and/or alter dose interval in patients with hepatic impairment
Reduce dose and/or alter dose interval in patients with renal impairment
Advice available from specialist unit for the use of this drug
Advise ability to drive/operate machinery may be affected by side effects
Before initiating therapy enquire about previous hypersensitivity reactions
Some formulations contain sucrose
Consider monitoring ECG in patients at risk of QT prolongation
In treatment of night cramps, reassess need for therapy every 3 months
Monitor serum electrolytes
Advise patient to report unexplained fever, sore throat, bruising, bleeding
Discontinue if severe hypersensitivity reactions occur
Discontinue, in treatment of night cramps, if symptoms of cinchonism occur

Quinine should be used with caution in patients with atrial fibrillation or other serious heart disease as it may cause hypoprothrombinaemia.

Use with caution in patients with glucose-6-phosphate dehydrogenase deficiency as there may be a risk of haemolysis in these patients.

Patients who have previously experienced adverse reactions to quinine including that in tonic water or other beverages should not be prescribed quinine.

Pregnancy and Lactation

Pregnancy

Quinine should be used with caution in pregnancy.

Quinine should be used only for the treatment of chloroquine-resistant malaria as the potential risk to the foetus due to treatment is much less than risks due to severe disease. Pregnant women treated with quinine are at risk of hypoglycaemia caused or exacerbated by quinine-induced hyperinsulinaemia.

High doses of quinine have been used to attempt induction of abortion and may cause congenital abnormalities of the CNS and extremities, and high doses have been associated with deafness and photosensitivity in the neonate. However, standard malaria treatment doses are considered to be safe in pregnancy.

Quinine is contraindicated in the treatment of nocturnal leg cramps during pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Quinine should be used with caution in breastfeeding.

Quinine is excreted in human breast milk. There is a potential risk of thrombocytopenia in neonates. Therefore quinine should only be used in breastfeeding if the benefits outweighs the risks.

Newborns at risk of glucose-6-phosphate dehydrogenase deficiency should not be breastfed until this disease can be ruled out.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Abortion
Acute renal failure
Agitation
Agranulocytosis
Altered colour perception
Angioedema
AV conduction disorders
Blindness
Blood disorders
Blurred vision
Bronchospasm
Cardiotoxicity
Cardiovascular effects
Cinchonism
Circulatory failure
CNS disturbances
Coma
Confusion
Decrease in blood pressure
Diarrhoea
Dyspnoea
Eczematous reactions
Erythema
Exacerbation of myasthenia gravis
Excitement
Fever
Gastro-intestinal disturbances
Haemoglobinuria
Haemolysis
Haemolytic uraemic syndrome
Headache
Hearing disturbances
Hot and flushed skin
Hypersensitivity reactions
Hypoglycaemia
Hypoprothrombinaemia
Intravascular coagulation
Lichen planus
Muscle weakness
Nausea
Oedema
Oliguria
Pancytopenia
Photosensitivity
Prolongation of QT interval
Pruritus
Rash
Renal impairment
T-wave changes
Thrombocytopenia
Thrombocytopenic purpura
Tinnitus
Unconsciousness
Urticaria
Vertigo
Visual disturbances
Visual field defects
Vomiting
Weak pulse
Widened QRS complex

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: June 2015

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Joint Formulary Committee. British National Formulary(online) London: BMJ Group and Pharmaceutical Press. Accessed on 03 June 2015.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications. Accessed on 03 June 2015.

Summary of Product Characteristics: Quinine Sulfate Tablets 200mg. Actavis UK Ltd. Revised April 2013.
Summary of Product Characteristics: Quinine Sulfate Tablets 300mg. Actavis UK Ltd. Revised April 2013.

Summary of Product Characteristics: Quinine Sulfate Tablets 200mg. Teva UK Ltd. Revised April 2012.
Summary of Product Characteristics: Quinine Sulfate Tablets 300mg. Teva UK Ltd. Revised April 2012.

Summary of Product Characteristics: Quinine Sulfate Tablets 300mg. Wockhardt UK Ltd. Revised January 2013.

The Renal Drug Handbook. Fourth Edition (2014) ed. Ashley, C and Dunleavy, A, Radcliffe Publishing Ltd, London.

MHRA Drug Safety Update June 2010
Available at: https://www.mhra.gov.uk
Last accessed: 3 June 2015.

UK Drugs in Lactation Advisory Service.
Available at: https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1
Last accessed: 3 June 2015.

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Quinine Last revised: 10 March 2015
Last accessed: 3 June 2015.