What is the Malarone (atovaquone/proguanil) dosing schedule for malaria prevention when traveling to a malaria endemic area?

Malarone Dosing Schedule for Malaria Prevention When Traveling to Endemic Areas

For malaria prevention when traveling to endemic areas, Malarone (atovaquone/proguanil) should be taken as one tablet daily (adult strength: 250 mg atovaquone/100 mg proguanil) starting 1-2 days before entering the malaria-endemic area, continuing daily during the stay, and for 7 days after return. 1

Dosing Details

Adult Dosing

• Adult dose: One tablet daily (250 mg atovaquone/100 mg proguanil)
• Timing: Take at the same time each day with food or a milky drink
• Duration:
  • Start: 1-2 days before entering malaria-endemic area
  • Continue: Throughout stay in endemic area
  • After return: Continue for 7 days after leaving the endemic area

Pediatric Dosing

For children, dosing is weight-based:

• Children ≥11 kg: Use pediatric tablets (62.5 mg atovaquone/25 mg proguanil)
  • 11-20 kg: 1 pediatric tablet daily
  • 21-30 kg: 2 pediatric tablets daily
  • 31-40 kg: 3 pediatric tablets daily

  • 40 kg: 1 adult tablet daily

Administration Considerations

• Take with food or a milky drink to enhance absorption
• If vomiting occurs within 1 hour of dosing, a repeat dose should be taken 1
• The daily regimen helps maintain effective blood levels of the medication
• Compliance is essential for effective prophylaxis

Special Populations

Renal Impairment

• Not recommended for malaria prophylaxis in patients with severe renal impairment (creatinine clearance <30 mL/min)
• No dosage adjustments needed for mild to moderate renal impairment 1

Hepatic Impairment

• No dosage adjustments needed for mild to moderate hepatic impairment
• Limited data available for severe hepatic impairment 1

Advantages of Malarone

1. Shorter post-travel dosing: Only requires 7 days of post-travel prophylaxis compared to 4 weeks with other antimalarials 2
2. Efficacy: Highly effective against drug-resistant strains of P. falciparum with estimated efficacy of 95-100% 2
3. Tolerability: Generally well-tolerated with fewer gastrointestinal adverse events than chloroquine plus proguanil, and fewer neuropsychiatric adverse events than mefloquine 2
4. Causal prophylaxis: Acts against both hepatic (pre-erythrocytic) and erythrocytic stages of P. falciparum 2

Common Pitfalls and Caveats

• Timing is critical: Starting just 1-2 days before travel is sufficient, unlike other antimalarials that require earlier initiation
• Compliance: Daily dosing must be maintained throughout the trip for effective protection
• Food requirement: Always take with food to maximize absorption and minimize gastrointestinal side effects
• Drug interactions: Be aware of potential interactions with other medications
• Not for everyone: Contraindicated in severe renal impairment and in individuals with hypersensitivity to the components

Alternative Dosing Considerations

While the FDA-approved regimen is daily dosing, some research suggests that twice-weekly dosing may provide protection for long-term travelers who have difficulty adhering to daily regimens. However, this approach is not FDA-approved and should not replace the standard daily dosing recommendation for most travelers 3.

Remember that no antimalarial regimen provides 100% protection, so additional protective measures against mosquito bites should always be employed, including using insect repellents, wearing protective clothing, and sleeping under insecticide-treated bed nets.