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Quinine

Scientific Name(s): Cinchona calisya Wedd., Cinchona ledgeriana Moens ex Trim. (yellow cinchona), Cinchona succirubra Pav. ex Klotsch (red cinchona)
Common Name(s): China bark, Cinchona bark, Fever tree, Jesuit's bark, Peruvian bark, Quina-quina, Red bark

Clinical Overview

Use

Quinine has been used for the treatment of malaria and associated febrile states, leg cramps caused by vascular spasm, internal hemorrhoids, varicose veins, and pleural cavities after thoracoplasty.

Dosing

Quinine has been widely studied as an antimalarial, and has been used at doses of 325 mg to 1 g as the sulfate salt. Classical doses of the crude bark were approximately 1 g.

Contraindications

Contraindications have not yet been identified.

Pregnancy/Lactation

Quinine has been previously listed as being contraindicated during pregnancy because of fetal and abortifacient effects.1 A review of the safety of antimalarial drugs in pregnancy state that standard (antimalarial) doses of quinine showed no evidence of increased risk of abortion or preterm delivery. Quinine has been shown to be secreted into breast milk, but insignificant amounts are ingested by the infant. However, high doses of quinine can cause uterine stimulation in pregnant women and deafness and optic nerve hypoplasia in children.2

Interactions

Rifamycins and cigarette smoking increase the elimination of quinine.3, 4, 5, 6, 7 Cimetidine3, 6 and ketoconazole4, 6 decrease the clearance of quinine. Serum levels of amantadine, carbamazepine, digoxin, phenobarbital, and warfarin may be elevated by quinine.3, 6, 8, 9 Quinine may enhance the effects of nondepolarizing muscle relaxants and succinylcholine. Close monitoring of neuromuscular function is required.6 Dosage adjustment may be necessary. For additional information please refer to the "Evidence-Based Herb-Drug Interactions" appendix.

Adverse Reactions

Quinine can cause cinchonism, hypoglycemia, serious hematologic disorders, urticaria, contact dermatitis, and other hypersensitivity reactions.

Toxicology

Quinine is rapidly absorbed from the GI tract and toxicity is dose related. Treatment of an overdose is generally supportive.

Scientific Family

Botany

The cinchonas are evergreen shrubs and trees that grow to heights of 15 to 31 m.10 They are native to the mountainous areas of tropical Central and South America, including regions of Bolivia, Costa Rica, and Peru. The oblong seed capsule is about 3 cm long and, when ripe, splits open at the base. Each capsule contains 40 to 50 slender seeds that are so light that approximately 75,000 seeds equal 30 g.11 In addition, these trees are found in cultivation in Africa and Southeast Asia.10, 12 At least one other genus (Remijia) of the same family has been reported to contain quinidine.13

History

The dried ground bark of the cinchona plant has been used for centuries for the treatment of malaria, fever, indigestion, mouth and throat diseases, and cancer.10, 11, 12 The name cinchona is said to be derived from the Countess of Chinchon, the wife of a viceroy of Peru, who it was long believed was cured in 1638 from a fever by the use of the bark;13 however, the story has been widely disputed. Formal use of the bark to treat malaria was established in the mid-1800s when the British began the worldwide cultivation of the plant11 in order to assure the continuing availability because the plant was in danger of extinction in some regions because of the harvesting of wild populations.13

Extracts of the bark have been used to treat hemorrhoids, to stimulate hair growth, and to manage varicose veins. Quinine has been used as an abortifacient.11 Extracts of cinchona have a bitter, astringent taste and have been used as flavoring for foods and beverages. Although the use of quinine for the treatment of malaria has been largely supplanted by semisynthetic antimalarials, its use persists in some regions of the world.

Chemistry

Typical cinchona bark contains about 16% of quinoline alkaloids consisting mainly of quinine, quinidine, cinchonine, and cinchonidine. The primary component of this mixture is quinine. Quinidine is the dextrorotatory isomer of quinine. Approximately 35 additional minor compounds related to quinine have been identified in the plant.10, 11 As a rule, the yellow cinchona has a higher alkaloid content than other varieties. Commercial formulations of quinine contain about 10% of dihydroquinine as an impurity.3

The cinchona alkaloids are extremely bitter tasting. Concentrations in the 100 to 300 ppm range are used to flavor beverages such as tonic water. Tonic water contains about 15 mg of quinine per bottle.14 Quinine may have tumor necrosis factor (TNF)-suppressive activity as demonstrated in one small study.8

Uses and Pharmacology

Quinine is eliminated mainly by hepatic metabolism with very little excreted unchanged in the urine.4, 5, 15 Cytochrome P450 3A4 has been shown to be important in the metabolism of quinine. Seven metabolites have been identified with 3-hydroxyquinine being the major metabolite.3, 4, 5, 16 In patients with acute renal failure who are infected with Plasmodium falciparum, up to 12% of antimalarial activity is due to the 3-hydroxyquinine metabolite.16

Antimalarial

Quinine is among the most potent of the cinchona alkaloids with respect to antimalarial activity.10 Resistant strains of Plasmodium have been identified. A small, in vitro study showed potential of phenobarbital to partially reverse quinine resistance.17 Calcium antagonists and other agents (eg, prochlorperazine) are being studied for reversing P. falciparum resistance to quinine.18 Various antibiotics (ie, artemisinin, artemether, clindamycin, doxycycline, mefloquine) in combination with quinine are being tested and used to treat resistant strains of P. falciparum.19, 20, 21, 22, 23, 24 If the oral route is not available for administration of quinine in children, effective alternate routes (ie, IM, intrarectal, IV) can be used.25, 26, 27, 28 Close monitoring for adverse reactions is advised, especially in young children who are more susceptible to quinine toxicity.26 The combination of quinine and clindamycin has been safely and effectively used in Thailand for the treatment of uncomplicated malaria.29

Antipyretic

Quinine has been thought to have antipyretic action.1 Although quinine administered before acetaminophen produces a more rapid drop in temperature than administration after acetaminophen, quinine alone has no effect on fever.30

Leg and other muscle cramps

Another common use of quinine has been for the treatment of leg cramps caused by vascular spasm. For more than 50 years, quinine, quinidine, and hydroquinine have been used to prevent muscle cramps.31 However, because 157 adverse drug reactions attributed to quinine were reported from 1969 to 1992, the Food and Drug Administration (FDA) concluded that quinine was not safe for use in this condition.32 In 1994, the FDA prohibited the marketing of quinine for nocturnal leg cramps and discontinued its availability and the labeling of products for this use in prescription and nonprescription form. 32, 33 However, a quick search of the Internet found a multitude of quinine preparations available and advertised for leg cramps.34

Clinical data

Various crossover, randomized trials, and 2 meta-analyses have confirmed that quinine is effective in the prevention of nocturnal leg cramps.31, 35, 36, 37

A Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology regarding the management of muscles cramps (2010) states that the use of quinine derivatives for treatment of muscle cramps is likely effective based on controlled studies; however, it should be avoided for routine treatment of cramps. According to this report, quinine should only be considered when cramps are very disabling, no other agents relieve symptoms, and there is careful monitoring of side effects. They should only be used after informing the patient of the potentially serious side effects.61

Other uses

Quinine is bacteriostatic, highly active in vitro against protozoa, and inhibits the fermentation of yeast.11

Quinine and quinidine have cardiodepressant activity. The latter compound is used for its antiarrhythmic activity.

A mixture of quinine and urea hydrochloride is injected as a sclerosing agent in the treatment of internal hemorrhoids, varicose veins, and pleural cavities after thoracoplasty.11

Quinine has been used to reverse multidrug resistance in patients with acute leukemias who express a higher incidence of P glycoprotein expression in blast cells. A high cure rate and better survival were shown in patients treated with combined quinine and chemotherapy when compared with chemotherapy alone. Although a higher incidence of side effects occurred, this combination has potential in treating acute leukemias.6, 38

Dosing

Quinine has been widely studied as an antimalarial, and has been used at doses of 325 mg to 1 g as the sulfate salt. Classical doses of the crude bark were approximately 1 g.

Detailed Quinine dosage information

Pregnancy / Lactation

Quinine has been previously listed as being contraindicated during pregnancy because of fetal and abortifacient effects.1 A review of the safety of antimalarial drugs in pregnancy state that standard (antimalarial) doses of quinine showed no evidence of increased risk of abortion or preterm delivery. Quinine has been shown to be secreted into breast milk, but insignificant amounts are ingested by the infant. However, high doses of quinine can cause uterine stimulation in pregnant women and deafness and optic nerve hypoplasia in children.2

Interactions

Quinine drug interactions (more detail)

Amantadine

In a randomized crossover study, administration of a single oral 200 mg dose of quinine decreased the renal clearance of a single oral dose of amantadine (3 mg/kg), increasing the plasma concentrations, in men but not women.39

Carbamazepine

The effect of a single 600 mg oral dose of quinine on the pharmacokinetics of a 200 mg oral dose of carbamazepine was studied in 6 healthy volunteers.40 Compared with giving carbamazepine alone, quinine administration increased the carbamazepine area under the plasma concentration-time curve (AUC) and peak plasma concentration 51% and 36.5%, respectively.

Nondepolarizing muscle relaxants

A 47-year-old patient receiving quinine (1800 mg daily) developed recurarization after reversal from anesthesia and administration of pancuronium (6 mg).7

Phenobarbital

The effect of a single 600 mg oral dose of quinine on the pharmacokinetics of a 120 mg oral dose of phenobarbital was studied in 6 healthy volunteers.40 Compared with giving phenobarbital alone, quinine administration increased the phenobarbital AUC and peak plasma concentration 45% and 35%, respectively.

Warfarin

There is no report of an interaction occurring with coadministration of quinine and warfarin. However, in healthy subjects, quinine (330 mg) administration prolonged the prothrombin time (form 5 to 11.8 seconds)41 and reduced the prothrombin content in blood in a patient receiving dicumarol (not available in the US).42 A similar interaction may be expected to occur with coadministration of quinine and warfarin.

Adverse Reactions

Quinine exhibits considerable inter- and intraindividual variations in metabolism and elimination, with differences also seen in healthy compared with malaria-infected patients. Adverse effects are dose-related.43

Quinine side effects (more detail)

Cardiac events

Because quinine is related to quinidine, ventricular fibrillation, prolongation of the QTc interval, and other adverse cardiac events can occur.18 Administration of IV quinine within 72 hours of mefloquine may cause QTc prolongation.22 Closely monitor patients with a cardiac history if quinine is given.

Cinchonism

The ingestion of these alkaloids can result in the clinical syndrome known as cinchonism. People who are hypersensitive to these alkaloids also may develop the syndrome, which is characterized by severe headache, abdominal pain, convulsions, visual disturbances and blindness, auditory disturbances such as ringing in the ears, paralysis, and collapse.10

Hematologic disorders

Therapeutic doses of quinine have resulted in acute hemolytic anemia12 a limitation for its use in patients who are glucose-6-phosphate dehydrogenase deficient.3 Quinine also has been associated with other serious hematologic disorders such as agranulocytosis, disseminated intravascular coagulation44, 45 hemolytic uremic syndrome (HUS)16, 44, 46, 47, 48, 49 neutropenia (leukopenia)50 pancytopenia with coagulopathy51, 52 and thrombocytopenia (the most common hematologic adverse effect).50, 53, 54, 55 Patients may present with one or several concomitant hematologic adverse events. Two deaths have been attributed to quinine-induced thrombocytopenia.53, 55

Hypersensitivity reactions

Ground cinchona bark and quinine have been reported to cause urticaria, contact dermatitis, and other hypersensitivity reactions. These reactions also may occur with the use of topical preparations containing cinchona extracts or quinine.11

Systemic hypersensitivity reactions can present as HUS, with acute renal failure and simulating sepsis.16, 49

Hypoglycemia

Children with severe malaria often present with hypoglycemia.56 Quinine has been shown to increase insulin secretion.57, 58 Quinine-induced hypoglycemia has been documented in patients with and without malaria.59, 60 Quinine-stimulated insulin release may be amplified in pregnancy, aggravating hypoglycemia.2 Monitor plasma glucose levels.

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Toxicology

Quinine and related alkaloids are rapidly absorbed from the GI tract; a single 2 to 8 g oral dose of quinine may be fatal to an adult.3, 11, 12 Treatment of an overdose is generally supportive. Urinary acidification can be employed if necessary.1 Quinine is not eliminated by hemofiltration or hemodialysis.15

References

1. Krishna S, Supanaranond W, Pukrittayakamee S, et al. Fever in uncomplicated Plasmodium falciparum infection: effects of quinine and paracetamol. Trans R Soc Trop Med Hyg. 1995;89:197-199.7778148
2. Phillips-Howard PA, Wood D. The safety of antimalarial drugs in pregnancy. Drug Saf. 1996;14:131-145.8934576
3. Krishna S, White NJ. Pharmacokinetics of quinine, chloroquine and amodiaquine. Clinical implications. Clin Pharmacokinet. 1996;30:263-269.8983859
4. Mirghani RA, Hellgren U, Westerberg PA, Ericsson O, Bertilsson L, Gustafsson LL. The roles of cytochrome P450 3A4 and 1A2 in the 3-hydroxylation of quinine in vivo. Clin Pharmacol Ther. 1999;66:454-460.10579472
5. Wanwimolruk S, Wong SM, Zhang H, Coville PF, Walker RJ. Metabolism of quinine in man: identification of a major metabolite, and effects of smoking and rifampin pretreatment. J Pharm Pharmacol. 1995;47:957-963.8708992
6. Wattel E, Solary E, Hecquet B, et al. Quinine improves the results of intensive chemotherapy in myelodysplastic syndromes expressing P glycoprotein: results of a randomized study. Br J Haematol. 1998;102:1015-1024.9734653
7. Drug Interactions Facts on Disc. [CD-ROM]. St. Louis, MO: Facts and Comparisons; July 2002.
8. Ittarat W, Udomsangpetch R, Chotivanich KT, Looareesuwan S. The effects of quinine and artesunate treatment on plasma tumor necrosis factor levels in malaria-infected patients. Southeast Asian J Trop Med Public Health. 1999;30:7-10.10695778
9. Wanwimolruk S, Kang W, Coville PF, Viriyayudhakorn S, Thitiarchakul S. Marked enhancement by rifampicin and lack of effect of isoniazid on the elimination of quinine in man. Br J Clin Pharmacol. 1995;40:87-91.8527275
10. Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. New York, NY: J. Wiley and Sons; 1980.
11. Morton JF. Major Medicinal Plants. Springfield, IL: C.C. Thomas Publisher; 1977.
12. Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press; 1985.
13. Evans WC. Trease and Evans' Pharmacognosy. 13th ed. Philadelphia, PA: W.B. Saunders, 1989.
14. Aster RH. Quinine sensitivity: a new cause of the hemolytic uremic syndrome [letter]. Ann Intern Med. 1993;119:243-244.8323094
15. Sharma AM, Keller F, Boeckh M, Heitz J, Borner K. Quinine dosage in severe malaria with renal failure necessitating haemodialysis. Eur J Clin Pharm. 1989;36:535-536.2753074
16. Newton P, Keeratithakul D, Teja-Isavadharm P, Pukrittayakamee S, Kyle D, White N. Pharmacokinetics of quinine and 3-hydroxyquinine in severe falciparum malaria with acute renal failure. Trans R Soc Trop Med Hyg. 1999;93:69-72.10492795
17. Mangou F, Platel DF, Haumont G. Plasmodium falciparum: modulation by phenobarbital of sensitivity to quinine, chloroquine and mefloquine in vitro. Trans R Soc Trop Med Hyg. 1998;92:561-562.9861380
18. Watt G, Na-Nakorn A, Bateman BN, et al. Amplification of quinine cardiac effects by the resistance-reversing agent prochlorperazine in falciparum malaria. Am J Trop Med Hyg. 1993;49:645-649.8250106
19. DeVries PJ, Bich NN, van Thien H, et al. Combinations of artemisinin and quinine for uncomplicated falciparum malaria: efficacy and pharmacodynamics. Antimicrob Agents Chemother. 2000;44:1302-1308.10770766
20. Kremsner PG, Radloff P, Metzger W. Quinine plus clindamycin improves chemotherapy of severe malaria in children. Antimicrob Agents Chemother. 1995;39:1603-1605.7492113
21. Metzger W, MordMüller B, Graninger W, Bienzle U, Kremsner PG. High efficacy of short-term quinine-antibiotic combinations for treating adult malaria patients in an area in which malaria is hyperendemic. Antimicrob Agents Chemother. 1995;39:245-246.7695315
22. Na-Bangchang K, Tan-Ariya P, Thanavibul A, Riengchainam S, Shrestha SB, Karbwang J. Pharmacokinetic and pharmacodynamic interactions of mefloquine and quinine. Int J Clin Pharmacol Res. 1999;19:73-82.10761536
23. Na-Bangchang K, Karbwang J, Ubalee R, Thanavibul A, Saenglertsilapachai S. Absence of significant pharmacokinetic and pharmacodynamic interactions between artemether and quinolone antimalarials. Eur J Drug Metab Pharmacokinet. 2000;25:171-178.11420886
24. Pukrittayakamee S, Chantra A, Vanijanonta S, Clemens R, Looareesuwan S, White NJ. Therapeutic responses to quinine and clindamycin in multidrug-resistant falciparum malaria. Antimicrob Agents Chemother. 2000;44:2395-2398.10952585
25. Barennes H, Pussard E, Mahaman Sani A, et al. Efficacy and pharmacokinetics of a new intrarectal quinine formulation in children with Plasmodium falciparum malaria. Br J Clin Pharmacol. 1996;41:389-395.8735679
26. van Hensbroek MB, Kwiatkowski D, van den Berg B, Hoek FJ, van Boxtel CJ, Kager PA. Quinine pharmacokinetics in young children with severe malaria. Am J Trop Med Hyg. 1996;54:237-242.8600757
27. Krishna S, Nagaraja NV, Planche T, et al. Population pharmacokinetics of intramuscular quinine in children with severe malaria. Antimicrob Agents Chemother. 2001;45:1803-1809.11353629
28. Schapira A, Solomon T, Julien M, et al. Comparison of intramuscular and intravenous quinine for the treatment of severe and complicated malaria in children. Trans R Soc Trop Med Hyg. 1993;87:299-302.8236398
29. McGready R, Cho T, Samuel. Randomized comparison of quinine-clindamycin versus artesunate in the treatment of falciparum malaria in pregnancy. Trans R Soc Trop Med Hyg. 2001;95:651-656.11816439
30. Olin BR, Hebel SK, eds. Drug Facts and Comparisons. St. Louis, MO: Facts and Comparisons; 1993.
31. Jansen PH, Veenhuizen KC, Wesseling AI, de Boo T, Verbeek AL. Randomised controlled trial of hydroquinine in muscle cramps. Lancet. 1997;349:528-532.9048790
32. U.S. Food and Drug Administration Updates: FDA orders stop to marketing of quinine for night leg cramps. Available at: http://www.fda.gov/fdac/departs/695_updates.html. Accessed April 15, 2004.
33. Nightingale SL. Quinine for nocturnal leg cramps. ACP J Club. 1995;123:86-87.7582738
34. Hyland's Leg Cramps with Quinine. Product Search. Available at: http://search.store.yahoo. Accessed September 6, 2002.
35. Connolly PS, Shirley EA, Wasson JH, Nierenberg DW. Treatment of nocturnal leg cramps. A crossover trial of quinine vs vitamin E. Arch Intern Med. 1992;152:1877-1880.1520054
36. Man-Son-Hing M, Wells G, Lau A. Quinine for nocturnal leg cramps: a meta-analysis including unpublished data. J Gen Intern Med. 1998;13:600-606.9754515
37. Man-Son-Hing M, Wells G. Meta-analysis of efficacy of quinine for treatment of nocturnal leg cramps in elderly people. BMJ. 1995;310:13-17.7827545
38. Solary E, Witz B, Caillot D, et al. Combination of quinine as a potential reversing agent with mitoxantrone and cytarabine for the treatment of acute leukemias: a randomized multicenter study. Blood. 1996;88:1198-1205.8695837
39. Gaudry SE, Sitar DS, Smyth DD, McKenzie JK, Aoki FY. Gender and age as factors in the inhibition of renal clearance of amantadine by quinine and quinidine. Clin Pharmacol Ther. 1993;54:23-27.8330461
40. Amabeoku GJ, Chikuni O, Akino C, Mutetwa S. Pharmacokinetic interaction of single doses of quinine and carbamazepine, phenobarbitone and phenytoin in healthy volunteers. East Afr Med J. 1993;70:90-93.8513749
41. Pirk LA, et al. Hypoprothrombinemic action of quinine sulfate. JAMA. 1945;128:1093-1095.
42. Jarnum S. Cinchophen and acetylsalicylic acid in anticoagulant treatment. Scand J Clin Lab Invest. 1954;6:91-93.13205128
43. Sowunmi A, Salako LA. Effect of dose size on the pharmacokinetics of orally administered quinine. Eur J Clin Pharmacol. 1996;49:383-386.8866633
44. Morton AP. Quinine-induced disseminated intravascular coagulation and haemolytic-uraemic syndrome. Med J Aust. 2002;176:351.12013332
45. Spearing RL, Hickton CM, Sizeland P, Hannah A, Bailey RR. Quinine-induced disseminated intravascular coagulation. Lancet. 1990;336:1535-1537.1979368
46. Glynne P, Salama A, Chaudhry A, Swirsky D, Lightstone L. Quinine-induced immune thrombocytopenic purpura followed by hemolytic uremic syndrome. Am J Kidney Dis. 1999;33:133-137.9915279
47. Gottschall JL, Elliot W, Lianos E, McFarland JG, Wolfmeyer K, Aster RH. Quinine-induced immune thrombocytopenia associated with hemolytic uremic syndrome: a new clinical entity. Blood. 1991;77:306-310.1898704
48. Story D, Hall A, Older P. Quinine-induced haemolytic uraemic syndrome. Anaesth Intensive Care. 1994;22:114-115.8160939
49. Schattner A. Quinine hypersensitivity simulating sepsis. Am J Med. 1998;104:488-490.9626033
50. Chuah TL, Denaro C. A case of quinine-induced thrombocytopenia and neutropenia. Aust N Z J Med. 2000;30:96.10800892
51. Maguire RB, Stroncek DF, Campbell AC. Recurrent pancytopenia, coagulopathy, and renal failure associated with multiple quinine-dependent antibodies. Ann Intern Med. 1993;119:215-217.8323089
52. Schmitt SK, Tomford JW. Quinine-induced pancytopenia and coagulopathy. Ann Intern Med. 1994;120:90-91.8250466
53. George JN, Raskob GE, Shah SR, et al. Drug-induced thrombocytopenia: a systematic review of published case reports. Ann Intern Med. 1998;129:886-890.9867731
54. Brasic JR. Quinine-induced thrombocytopenia in a 64-year-old man who consumed tonic water to relieve nocturnal leg cramps. Mayo Clin Proc. 2001;76:863-866.11499830
55. Freiman JP. Fatal, quinine-induced thrombocytopenia [letter]. Ann Intern Med. 1990;112:308-309.2297210
56. Agbenyega T, Angus BJ, Bedu-Addo G, et al. Glucose and lactate kinetics in children with severe malaria. J Clin Endocrinol Metab. 2000;85;1569-1576.10770199
57. Davis TM, Karbwang J, Looareesuwan S, Turner RC, White NJ. Comparative effects of quinine and quinidine on glucose metabolism in healthy volunteers. Br J Clin Pharmac. 1990;30:397-403.2223418
58. Davis TM. Antimalarial drugs and glucose metabolism. Br J Clin Pharmacol. 1997;44:1-7.9241090
59. Limburg PJ, Katz H, Grant CS, Service FJ. Quinine-induced hypoglycemia. Ann Intern Med. 1993;119:218-219.8323090
60. Harats N, Ackerman Z, Shalit M. Quinine-related hypoglycemia [letter]. N Engl J Med. 1984;310:1331.6717500
61. Katzberg HD, Khan AH, So YT. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American academy of neurology. Neurology. 2010;74(8):691-696. 20177124

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