Notices to Readers Change of Dosing Regimen for Malaria Prophylaxis with Mefloquine

CDC recommends mefloquine (Lariam R) alone as the drug of choice for malaria prevention for travelers to areas with drug-resistant Plasmodium falciparum malaria (1-4).* Based on accumulating experience with this drug, the prophylactic dosing regimen has been revised to a single dose of mefloquine to be taken every week (3). The first dose should be taken 1 week before travel. It should be continued weekly during the entire period of travel in malarious areas and for 4 weeks after departure from such areas.

The previous dosing regimen (in which one dose was taken each week for 4 weeks, followed by one dose every other week) compromises the effectiveness of mefloquine. Malaria prophylaxis with this dosing regimen among Peace Corps volunteers in West Africa was less effective than expected (5). The relatively low effectiveness was due to the every-other-week dosing regimen because all mefloquine prophylaxis failures occurred during the second week of the alternate-week dosing regimen in volunteers who had used mefloquine greater than 2 months. Mean mefloquine blood concentrations were substantially lower during the second week of the every-2-weeks dosing regimen than during the first week, suggesting that during the second week blood levels are too low to suppress parasitemia (5).

All studies confirm that mefloquine is well tolerated when used for prophylaxis. No serious adverse reactions to mefloquine prophylaxis (i.e., psychoses and convulsions) have been observed among Peace Corps volunteers or among 18,462 persons enrolled in prophylactic drug trials and surveys of travelers who were taking mefloquine weekly (5). However, serious adverse reactions have been reported, especially when mefloquine was used for treatment of patients with malaria. Because mefloquine has been used in the United States for only 18 months, monitoring of adverse reactions remains important. Physicians are encouraged to report serious adverse reactions in persons using mefloquine to CDC's Malaria Branch, Division of Parasitic Diseases, Center for Infectious Diseases; telephone (404) 488-4046.

Consistent with previous guidelines, mefloquine is not recommended for use by travelers with known hypersensitivity to mefloquine; children less than 15 kg (30 lbs); pregnant women; travelers using beta blockers; travelers involved in tasks requiring fine coordination and spatial discrimination, such as airplane pilots; and travelers with histories of epilepsy or psychiatric disorder (1,2).

Travelers to areas of risk where chloroquine-resistant P. falciparum is endemic and for whom mefloquine is contraindicated may elect to use daily doxycycline alone or chloroquine alone. If chloroquine is used, the traveler needs to be aware of the need to seek medical attention for febrile episodes and to carry a treatment dose of pyrimethamine-sulfadoxine (Fansidar R) to be used if medical care is not available within 24 hours (1,2).

The CDC publication Health Information for International Travel (2) provides detailed information for each country on the risk for malaria to travelers and on the presence of drug-resistant P. falciparum (1). Health information for travelers is available 24 hours a day from the CDC automated telephone system at (404) 332-4555.

Periodic shortages of mefloquine have occurred in the United States. Travelers who cannot obtain mefloquine before departure may be able to purchase it in Europe while in transit to countries with endemic malaria. Prescriptions written in the United States are accepted at airport pharmacies in Frankfurt and Paris (both Charles de Gaulle and Orly airports). The pharmacy at Heathrow Airport in London requires prescriptions written in Great Britain. At the airport pharmacy in Brussels, a prescription from the airport physician is required. Mefloquine is not available at the airports in Amsterdam and Rome and at Gatwick (London).

In some countries, a fixed combination of mefloquine and pyrimethamine-sulfadoxine is marketed under the name Fansimef R. Fansimef R should not be confused with mefloquine, and it is not recommended for prophylaxis of malaria. Reported by: Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

References

1. CDC. Recommendations for the prevention of malaria among travelers. MMWR 1990;39 (no. RR-3).

2. CDC. Health information for international travel, 1990. Atlanta: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8280.

3. CDC. Revised dosing regimen for malaria prophylaxis with mefloquine. MMWR 1990;39:630.

4. Lackritz EM, Lobel HO, Howell J, Bloland P, Campbell CC. Imported Plasmodium falciparum malaria in American travelers to Africa. JAMA 1991;265:383-5.

5. Lobel HO, Bernard KW, Williams SL, Hightower AW, Patchen L, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a better dosing regimen. JAMA 1991;265:361-4.

• This revision replaces the recommended mefloquine dosing

regimen in reference 1, page 4 and figure 2, and reference 2, page 98.

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