Quinine

What is Quinine

Quinine is an alkaloid that occurs naturally in the bark of the cinchona tree. The benefits of cinchona bark were first recognized in 1630 in South America, where cinchona is indigenous to certain regions.

By 1640 it was introduced into Spain for the treatment of fever. The early use of quinine for all types of febrile illness was erroneous and stemmed from the observed reduction of fever in malarial patients; it does not have antipyretic qualities.

Quinine was isolated from cinchona bark in 1820 and is still obtained from the natural source. It is the levorotatory isomer of quinidine, a more potent, but more toxic, antimalarial.

Quinine is approved for use in treating chloroquine-resistant malaria due to strains of Plasmodium falciparum; it is not approved for the prevention of malaria. There are serious safety concerns associated with the use of quinine; since 1969, the FDA has received 665 reports of adverse events with serious outcomes associated with quinine use, including 93 deaths. Because malaria is a life-threatening illness, the risks associated with quinine use are justified for treatment.

However, quinine is used off-label (on both an OTC and prescription basis) for the relief of nocturnal muscle cramping and, because of the risks associated with its use, both the manufacturer of the approved prescription product and the FDA warn against such use (see Contraindications).

In December 1995, non-prescription forms of quinine were removed from the market; as of December 2006 unapproved formulations were still found to be available.

The product manufactured by Mutual Pharmaceutical Company, Inc., a prescription-only drug, is the only quinine product approved by the FDA.

Brand Name

Qualaquin

Indications

  1. Babesia microti
  2. babesiosis
  3. malaria
  4. Plasmodium falciparum
  5. Plasmodium malariae
  6. Plasmodium ovale
  7. Plasmodium vivax

Side Effects

  1. abdominal pain
  2. agranulocytosis
  3. anorexia
  4. aphasia
  5. aplastic anemia
  6. ataxia
  7. atrial fibrillation
  8. AV block
  9. bleeding
  10. blurred vision
  11. bradycardia
  12. bullous rash
  13. cardiac arrest
  14. chest pain (unspecified)
  15. coagulopathy
  16. coma
  17. confusion
  18. contact dermatitis
  19. diaphoresis
  20. diarrhea
  21. diplopia
  22. disseminated intravascular coagulation (DIC)
  23. dizziness
  24. dyspnea
  25. dystonic reaction
  26. ecchymosis
  27. erythema
  28. erythema multiforme
  29. esophagitis
  30. exfoliative dermatitis
  31. fever
  32. headache
  33. hearing loss
  34. hemolysis
  35. hemolytic anemia
  36. hemolytic-uremic syndrome
  37. hepatitis
  38. hypoglycemia
  39. hypoprothrombinemia
  40. hypotension
  41. infertility
  42. interstitial nephritis
  43. jaundice
  44. leukopenia
  45. lupus-like symptoms
  46. maculopapular rash
  47. myalgia
  48. nausea
  49. neutropenia
  50. night blindness
  51. optic atrophy
  52. optic neuritis
  53. orthostatic hypotension
  54. palpitations
  55. pancytopenia
  56. peripheral vasodilation
  57. petechiae
  58. photophobia
  59. photosensitivity
  60. premature ventricular contractions (PVCs)
  61. pruritus
  62. pulmonary edema
  63. QT prolongation
  64. renal failure (unspecified)
  65. restlessness
  66. scotomata
  67. seizures
  68. sinus tachycardia
  69. Stevens-Johnson syndrome
  70. suicidal ideation
  71. syncope
  72. thrombocytopenia
  73. thrombotic thrombocytopenic purpura (TTP)
  74. tinnitus
  75. torsade de pointes
  76. toxic epidermal necrolysis
  77. tremor
  78. urticaria
  79. vasculitis
  80. ventricular fibrillation
  81. ventricular tachycardia
  82. vertigo
  83. visual impairment
  84. vomiting
  85. weakness

Monitoring Parameters

  • blood glucose
  • CBC
  • ECG
  • ophthalmologic exam

Contraindications

  • alcoholism
  • blackwater fever
  • bradycardia
  • breast-feeding
  • cardiac arrhythmias
  • cardiac disease
  • coronary artery disease
  • diabetes mellitus
  • females
  • G6PD deficiency
  • heart failure
  • hemolytic-uremic syndrome
  • hepatic disease
  • hypertension
  • hypocalcemia
  • hypoglycemia
  • hypokalemia
  • hypomagnesemia
  • infertility
  • intramuscular injections
  • long QT syndrome
  • malnutrition
  • mefloquine hypersensitivity
  • muscle cramps
  • myasthenia gravis
  • myocardial infarction
  • optic neuritis
  • pregnancy
  • QT prolongation
  • quinidine hypersensitivity
  • quinine hypersensitivity
  • reproductive risk
  • thrombocytopenia
  • thrombotic thrombocytopenic purpura (TTP)
  • thyroid disease
  • tinnitus

Interactions

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