What is the first-line treatment for severe malaria?

Intravenous or intramuscular artesunate, given for at least 24 hours and until the patient can swallow, followed by a complete 3-day ACT course.

What if artesunate is not available?

WHO recommends parenteral artemether in preference to quinine. For pre-referral care, a single IM dose of artesunate (or rectal artesunate suppository in young children) before transfer.

Severe Malaria Treatment: Injectable Artesunate (WHO First-Line)

A medical emergency with a clear answer

Untreated severe malaria — especially cerebral malaria — kills close to 100% of patients. With prompt, effective treatment and supportive care, mortality falls to 10–20%. The drug that makes the difference, recommended by WHO with strong recommendation and high-certainty evidence, is injectable artesunate.

The WHO treatment protocol

Start immediately: intravenous (IV) or intramuscular (IM) artesunate for at least 24 hours, and until the patient can tolerate oral medicine.
Finish the course: once the patient can swallow, complete treatment with a full 3-day ACT.
Children under 20 kg need a higher dose: 3 mg/kg per dose, versus 2.4 mg/kg for older children and adults, because their drug exposure is otherwise too low.

When artesunate is not available

WHO is explicit: use parenteral artemether in preference to quinine. Quinine injection remains a last-resort alternative where neither artesunate nor artemether is available — it works, but is slower, needs cardiac monitoring, and causes more side effects.

Before the hospital: pre-referral treatment

Severe malaria patients often die in transit. WHO therefore recommends giving treatment before referral when full care is not possible:

A single IM dose of artesunate where injections are feasible;
If not, IM artemether;
For young children where no injection is available, a rectal artesunate suppository before transfer to a facility that can give definitive care.

Procurement notes

Hospital tenders for severe malaria typically specify artesunate powder for injection (with diluent), artemether injection for backup, and rectal artesunate suppositories for community-level pre-referral programs. Verify cold-chain requirements, reconstitution instructions and shelf life when comparing offers.

Source: summarised in plain language from the WHO Guidelines for Malaria (10 September 2026), World Health Organization. This guide is for buyer education only — clinical decisions must follow the locally approved product insert and national treatment guidelines.