LARINATE-120

Indications

• Severe malaria caused by _Plasmodium falciparum_
• Uncomplicated malaria in combination with other antimalarial agents

Dosage

Adults: For adults, the typical dosing regimen is an initial dose of 2.4 mg/kg intravenously, followed by 1.2 mg/kg at 12 and 24 hours, with subsequent doses depending on clinical response

Mechanism of action

Artesunate is metabolized to dihydroartemisinin (DHA), which reacts with heme, generating free radicals that inhibit protein and nucleic acid synthesis in _Plasmodium_ parasites during all erythrocytic stages. This interaction with free radicals can lead to the alkylation of essential parasitic proteins, disrupting their normal function. Two primary theories explain its action: one suggests that artemisinins are activated by interaction with ferrous iron or reduced heme, producing reactive radicals that alkylate biomolecules; the other posits that the intact artemisinin binds to vital proteins in the parasite, leading to the formation of reactive oxygen species.

Pharmacodynamics

As an artemisinin derivative, artesunate is metabolized to dihydroartemisinin, which generates free radicals that inhibit the function of _Plasmodium_ parasites. It has a short duration of action due to its short half-life, and while it possesses a moderate therapeutic index, patients should be informed about potential post-treatment hemolytic anemia and hypersensitivity reactions.

Pharmacokinetics

Artesunate is rapidly absorbed and converted to DHA, which has a short half-life. The pharmacokinetics of artesunate can be influenced by factors such as the presence of food and other medications. It is primarily metabolized in the liver and excreted in urine, with a rapid onset of action that makes it suitable for emergency treatment of severe malaria.

Adverse effects

• Hypersensitivity reactions
• Hemolytic anemia
• Gastrointestinal disturbances
• Headache
• Dizziness
• Fatigue

Precautions

• Caution in patients with a history of hypersensitivity to artemisinin derivatives
• Monitor for signs of hemolytic anemia
• Use with caution in patients with liver impairment

Pregnancy

Artesunate is classified as category C. The risks versus benefits should be assessed before use in pregnant women.

Breast-feeding

It is not known if artesunate is excreted in human milk. Caution is advised when administering to breastfeeding women.

Storage

Store at room temperature (15-30 degrees Celsius) in a tightly closed container, protected from light and moisture.

Formulations

• Injectable solution
• Oral tablets

Indications

• Metabolic acidosis
• Renal tubular acidosis
• Urinary alkalinization
• Gastric hyperacidity
• Cardiac arrest (in certain protocols)
• Acid-base disturbances in patients with chronic kidney disease

Dosage

Children: Refer to BNF for Children for appropriate dosing guidelines.

Adults: Refer to specific clinical guidelines and BNF for exact dosing as it can vary based on condition and clinical scenario.

Mechanism of action

Bicarbonate acts by increasing the pH of the blood and urine, thereby reducing acidity. It dissociates into sodium ions and bicarbonate ions, which then combine with hydrogen ions to form carbonic acid. This reaction helps to buffer excess hydrogen ions in the body, effectively neutralizing acid and increasing the blood's alkalinity. The bicarbonate ion is a key component in the bicarbonate buffer system, which helps maintain acid-base homeostasis.

Pharmacodynamics

The pharmacodynamic effects of bicarbonate include its ability to correct metabolic acidosis by providing a source of bicarbonate to the body, which is essential for maintaining pH balance. Its action can lead to increased plasma bicarbonate levels, thereby reducing the acidity of the blood and enhancing oxygen delivery to tissues. Additionally, it can affect the solubility of other compounds and may influence renal excretion of certain electrolytes.

Pharmacokinetics

Bicarbonate is rapidly absorbed from the gastrointestinal tract when administered orally. Its distribution occurs widely throughout body fluids, with a significant portion being buffered by plasma proteins. The elimination of bicarbonate occurs primarily through renal excretion, where it can be reabsorbed or excreted depending on the body's acid-base status. The half-life of bicarbonate is variable and primarily influenced by the rate of renal clearance.

Adverse effects

• Metabolic alkalosis
• Electrolyte imbalances
• Gastrointestinal disturbances
• Tissue hypoxia

Interactions

• May interact with other alkaline drugs
• May affect the absorption of certain medications due to changes in gastric pH

Precautions

• Use with caution in patients with renal impairment
• Monitor electrolyte levels during treatment
• Avoid rapid administration to prevent complications

Pregnancy

Generally considered safe when used appropriately, but should be used under medical supervision.

Breast-feeding

Considered safe but consult healthcare provider for individual assessment.

Storage

Store in a cool, dry place, protected from light.

Formulations

• Sodium bicarbonate powder
• Sodium bicarbonate injection
• Sodium bicarbonate tablets
• Sodium bicarbonate oral solution

Mechanism of action

Artesunate is metabolized to the active DHA. the endoperoxide bridge of DHA reacts with heme, generating free radicals which inhibit protein and nucleic acid synthesis of the _Plasmodium_ parasites during all erythrocytic stages. Reactions with these free radicals can also lead to alkylation of parasitic proteins such as a calcium adenosine triphosphatase and EXP1, a glutathione S-transferase. Two theories have been put forward for the mode of antimalarial action of the artemisinin antimalarials, in accodance with the known properties of peroxides with medicinal activity. The first assumes that the artemisinins must be activated by contact with either reduced haem (ferrous haem, Fe(ll)PPIX) or non-haem ferrous iron (exogenous iron), causing cleavage of the peroxide to generate oxygen-centered radicals (alkoxy radicals') which are the presumed to be converted into carbon-centered radicals by transfer of proximate hydrogen atoms from the periphery of the peroxide molecule. These carbon-centered radicals are then thought to alkylate sensitive, yet unspecified, biomolecules in the parasite. A second theory argues for a process in which the intact artemisinin binds to a site within a vital protein in the parasite. The act of binding causes the peroxide to be converted to hydroperoxide or similar open peroxide, which in accordance with known properties of such compounds, generates one or more active chemical entities, either oxidizing agents or oxygen transfer agents per se, or oxygen-centered free radicals. This would be associated with the binding process. In such a way, the artemisinins might act as (irreversibile) inhibitors. Iron may, or may not, be associated with the activation process. No specific biological target in the parasite has yet been identified in support of this theory, but it may be membrane-bound proteins. Artesunate is a water soluble derivative of artemisinin, an antimalarial compound isolated from the Chinese herb Qinghao (Artemisia annua). Artesunate is rapidly metabolized to dihydroartemisinin (DHA) in the body. Chemically, artesunate, and its active metabolite, DHA, are sesquiterpene lactones with a trioxane ring containing a peroxide bridge. The peroxide bridge appears to be essential for the antimalarial activity of artesunate. Structure-activity relationship studies show that the deoxy derivative of DHA (that lack the peroxide bridge) was 277-fold less active than DHA. The activity of deoxyartesunate was not measured. Deoxy derivatives of other artemisinin analogs were 10- to 1000-fold less active compared to the parent compounds. Artesunate increases superoxide anion production and lipid peroxidation in falciparum-infected erythrocytes in vitro. However, artesunate does not suppress the activity of antioxidant enzymes (superoxide dismutase, catalase, glutathione reductase, and glutathione peroxidase) in infected or uninfected erythrocytes. Erythrocytes infected with the ring or trophozoite forms in vitro accumulate 100- and 180- fold higher concentrations of DHA (12 nM ie, 3.40 ng/mL), respectively, compared to uninfected erythrocytes. These experiments were performed in a medium containing 10% human serum. The relevance of these findings to the uptake in vivo is unclear. The precise mechanism by which artesunate exhibits antiplasmodial activity is not understood. A 2025 systematic review notes Artesunate's pharmacological activities (antimalarial, antiparasite,antitumor, antivirus, antiinflammation, and antibacterial),and that it is a highly effective antimalarial agent with the potential to induce organ toxicity under certain conditions. The authors note that mechanisms of Artesunate-induced toxicity include oxidative stress, inflammation, and apoptotic signaling patthhways.They also note that Artesunate ameliorates MASH (Metabolic Dysfunction-Associated Steatohepatitis) by reducing inflammation and lipid accumulation by regulating NLRP3 inflammasome and reducing lipid accumulation (SREBP-1c, FAS).

Pharmacodynamics

Artesunate is an artemisinin derivative that is metabolized to DHA, which generates free radicals to inhibit normal function of _Plasmodium_ parasites. It has a short duration of action due to its short half life, and a moderate therapeutic index. Patients should be counselled regarding the risk of post treatment hemolytic anemia and hypersenstivity.