What are the options for Malaria (Plasmodium infection) prophylaxis medication?

From the Guidelines

For malaria prevention, mefloquine (Lariam) is recommended as the drug of choice for travelers at risk of infection with chloroquine-resistant P. falciparum, as stated in the study by 1. When considering malaria prevention medication, it's essential to weigh the options based on the destination and resistance patterns.

• Mefloquine is expected to be highly effective against both chloroquine-resistant and Fansidar-resistant P. falciparum infections, according to 1.
• Alternative drugs for travelers who cannot take mefloquine include doxycycline alone or chloroquine alone, with Fansidar available for standby treatment, as mentioned in 1.
• Chloroquine can be used in areas without resistant malaria strains, and its prophylaxis can begin 1-2 weeks before travel to malarious areas, continued weekly during travel, and for 4 weeks after leaving such areas, as stated in 1.
• It's also important to note that P. vivax and P. ovale have forms that can persist in the liver and cause relapses for as long as 4 years after routine chemoprophylaxis is discontinued, and primaquine can decrease the risk of relapses, as discussed in 1. Beyond medication, preventive measures such as using insect repellent containing DEET, wearing long sleeves and pants from dusk to dawn, sleeping under insecticide-treated bed nets, and using air conditioning when available are crucial.
• Consultation with a travel medicine specialist is necessary before the trip, as resistance patterns vary by region, and some medications have contraindications based on medical history.

From the FDA Drug Label

Prevention of Malaria: Atovaquone and proguanil hydrochloride was evaluated for prophylaxis of malaria in 5 clinical trials in malaria-endemic areas and in 3 active-controlled trials in non-immune travelers to malaria-endemic areas Prophylaxis: Doxycycline is indicated for the prophylaxis of malaria due to Plasmodium falciparum in short-term travelers (<4 months) to areas with chloroquine and/or pyrimethamine-sulfadoxine resistant strains Prevention of Malaria Mefloquine is indicated for the prophylaxis of P. falciparum and P. vivax malaria infections, including prophylaxis of chloroquine-resistant strains of P. falciparum.

The medications atovaquone and proguanil hydrochloride 2, doxycycline 3, and mefloquine 4 can be used for malaria prevention.

• Atovaquone and proguanil hydrochloride is used for prophylaxis of malaria in malaria-endemic areas and in non-immune travelers to malaria-endemic areas.
• Doxycycline is used for prophylaxis of malaria due to Plasmodium falciparum in short-term travelers to areas with chloroquine and/or pyrimethamine-sulfadoxine resistant strains.
• Mefloquine is used for prophylaxis of P. falciparum and P. vivax malaria infections, including prophylaxis of chloroquine-resistant strains of P. falciparum.

From the Research

Malaria Prevention Medication

• Atovaquone/proguanil is a fixed-dose combination tablet of two antimalarial agents and is highly effective for the prevention of Plasmodium falciparum malaria 5.
• The combination of atovaquone and proguanil is active against hepatic (pre-erythrocytic) stages of P. falciparum, thereby providing causal prophylaxis and eliminating the need to continue post-travel treatment beyond 7 days 5.
• Atovaquone/proguanil is highly effective against drug-resistant strains of P. falciparum, and cross-resistance has not been observed between atovaquone and other antimalarial agents 5.

Efficacy of Atovaquone/Proguanil

• In comparative, randomised clinical trials, there were no cases of P. falciparum malaria in nonimmune adults, adolescents and children (≥11 kg) visiting malaria-endemic regions for ≤28 days and receiving atovaquone/proguanil (250/100 mg in adults and dosage based on bodyweight in children <40 kg) once daily 5.
• The efficacy for the prevention of P. falciparum malaria was estimated at 100% for atovaquone/proguanil and for mefloquine, and 70% for chloroquine plus proguanil 5.
• In individuals (≥11 kg) from endemic regions who may carry some immunity to malaria (semi-immune), the prophylactic efficacy rating for atovaquone/proguanil based on placebo-controlled trials was 95-100% 5.

Tolerability and Adverse Events

• Atovaquone/proguanil is generally well tolerated by both adults and children 5, 6.
• The most common treatment-related adverse events in placebo-controlled trials were headache and abdominal pain, which occurred at a rate similar to that observed with placebo 5.
• Atovaquone/proguanil therapy was associated with significantly fewer gastrointestinal adverse events than chloroquine plus proguanil, and significantly fewer neuropsychiatric adverse events than mefloquine in nonimmune individuals 5, 6.

Recommendations for Use

• Atovaquone/proguanil is recommended as first choice for malaria chemoprophylaxis for adult travellers with no co-morbidities travelling for 2 weeks (91.67% of experts) and for 2 months (51.06%) 7.
• Mefloquine was the first choice for a healthy tourist child travelling for 2 months (59.57%), for a tourist infant (8 kg) travelling for 2 weeks (59.57%) and for 2 months (68.09%), for a pregnant VFR (74.47%), for a breast-feeding mother with her 5 kg infant (72.34%) and for a VFR family with limited budget (63.83%) 7.