Guidelines for preventive malaria pills (malaria prohylaxis)

For areas with resistance against chloroquine or fansidar (ZONE C on the malaria map)  :

ATOVAQUONE 250 MG/PROGUANIL 100 MG: for an adult: 1 tablet daily,  starting 1 day before arrival in the malaria risk area until 7 days after leaving risk area.  Atovaquone/Proguanil should be taken preferably during a meal or with milk. It may be taken for several months (= much longer than the 4 weeks stated in the product leaflet; but keep the high price in consideration).  Atovaquone/Proguanil can be given to children from 5 kg, in an adapted dose. Atovaquone/Proguanil is exceptionnaly given to pregnant women or breast feeding women.

DOXYCYCLINE 100 MG: for an adult 1 tablet of 100 mg or ½ tablet of 200 mg daily, 1 day before arrival in the malaria risk area until 4 weeks after leaving risk area; doxycycline should be taken with plenty of liquid or during a meal. May be taken for several months. Doxycycline must not be given to children < 8 years and in exceptional cases, if no alternatives are available, to pregnant women during the first trimester of their pregnancy and to lactating women. Doxycycline can sometimes cause fungal infections of the mouth and the genitals and may give rise to phototoxic rash (sun allergy).

MEFLOQUINE 250 MG – LARIAM®:  1 tablet per week, on a fixed day, during the evening meal, until 4 weeks after return or after leaving risk area. Lariam® is not given to children who weigh less than 5 kg. Lariam® can be given to pregnant women during the entire pregnancy and to lactating women. Less effective in different areas of Thailand, Myanmar and Cambodia.

  1. CONTRAINDICATIONS to be discussed with the doctor
    1. Depression, suicidal thoughts
    2. Other psychiatric problems like anxiety disorder (anxiety attacks), schizophrenia or psychosis (loss of contact with reality)
    3. Convulsions (epilepsy)
    4. Heart arrhythmia
    5. Previous intake not well tolerated, allergy for quinine, quinidine or Lariam
    6. Severe liver complaints or black water fever (a complication of malaria attacking the blood and kidneys)
  2. START : 3 tablets should be taken before departure
    1. If never taken previously and sufficient time before departure:
      1. “Test tolerance”
        = 1 tablet per week 2-4 weeks before departure
        at least 3-4 tablets before departure  
    2. Classic scheme
      1. Take 1 tablet per week, at least 2 week(s) before departure or take 1 tablet per day during 2 days, at least 1 week before departure(medication build up) and then 1 tablet per week.
    3. If taken previously and well tolerated and no time before departure, only in case of high malaria risk:
      1. Take 1 tablet per day for 3 consecutive days just before departure (medication build up), and then 1 tablet per week
  3. POSSIBLE ADVERSE EFFECTS:
    1. The majority of people can take Lariam® without any problem
    2. May be taken for many months
    3. Stop taking this medication immediately and definitively in case of severe adverse effects!
    4. Possible adverse effects:
      1. dizziness
      2. nightmares
      3. insomnia
      4. restlessness
      5. confusion
      6. headache
      7. shortness of breath
      8. unusual mood swings
      9. paranoia
      10. aggressive behaviour
      11. suicidal thoughts
      12. selfdestructive behaviour
      13. psychosis
      14. hallucinations
      15. palpitation
      16. gastro-intestinal complaints
    5. 75% of the symptoms of intolerance occur after taking 3 tablets; 95% if 6 tablets are well tolerated; the risk of adverse effects decreases with the duration of tolerance.  Delayed adverse effects are possible and can be related to stress, fatigue and/or insomnia.
    6. Extremely rare: epilepsy, hallucination (1/10.000)
    7. Because these adverse effects may appear very gradually, they are often noticed relatively late – be aware of this.
      Consider stopping Lariam® if too troublesome and switch to another prophylaxis. In case of side effects, discuss this as soon as possible with your treating doctor. 
  4. ALTERNATIVES:
    1. Atovaquone/Proguanil: 1 tablet per day. When switching from a different prophylaxis to Malarone during or after a stay in a malaria region (or when one has forgotten to take 1 or 2 pills), Malarone should always be continued until at least 4 weeks after the switch – this means Atovaquone/Proguanil sometimes must be taken longer than the prescribed 7 days after leaving the malaria region:
      1. Switch 3 weeks before departure: once daily for the rest of the stay  – until 7 days after leaving the risk area
      2. Switch < 3 weeks before departure: once daily until 4 weeks after the switch
      3. Switch after departure (=after leaving the risk area); once daily for another 4 weeks
        Atovaquone/Proguanil has an efficiency of > 95% and can easily be used during several months (taking into consideration the high price).
    2. Doxycycline  (1 tablet of 100 mg or ½ tab. of 200 mg /day, to be started 1 day before departure until 4 weeks after return), to be discussed with the doctor. Not for children under the age of 8 yearsDoxycycline may be administered in exceptional cases, if no alternatives are available, to pregnant women during the first trimester of their pregnancy and to lactating women. Doxycycline should be taken in a sitting position, with plenty of liquid, or during the meal (ulcer in the oesophagus).  Can cause fungal infections of the mouth and the genitals and photosensitivity (excessive skin reaction after sun exposure).
      Doxycycline is > 95 % effective and can be taken for several months.

These medications are only available on doctor’s prescription.

No drug offers 100% protection, so if fever occurs within the first three months after your return from the tropics, one should think of malaria and seek immediately competent medical aid. However, it is reassuring to know that malaria, provided it is recognised in time, is easy to treat without any danger of recurrent attacks. The belief that “once malaria always malaria” is totally untrue.

For more info, contact us

Source: Institute for Tropical Medicine – Antwerp – Belgium

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antwerp Port Pharmacy, Sint-Jansplein 8-9, 2060 Antwerp

+32 (0)3 233 68 57|info@antport.be|www.antport.be|APB 110339