What is the recommended medication for malaria prevention?

Recommended Medications for Malaria Prevention

For travelers to areas with chloroquine-resistant Plasmodium falciparum, mefloquine is the recommended first-line medication for malaria prevention. 1

Medication Selection Algorithm Based on Travel Destination

For areas where chloroquine-resistant P. falciparum has NOT been reported:

• First choice: Chloroquine alone (weekly dosing)
  • Begin 1-2 weeks before travel
  • Continue weekly during travel
  • Continue for 4 weeks after leaving malarious area
  • Well-tolerated with rare serious adverse reactions at prophylactic doses 1

For areas where chloroquine-resistant P. falciparum exists:

• First choice: Mefloquine alone (weekly dosing)

  • 250 mg (adult dose) once weekly
  • Continue for 4 weeks after leaving malarious area 1

• Alternative options (if mefloquine is contraindicated):

  1. Doxycycline (daily dosing)

     • Begin 1-2 days before travel
     • Continue daily during travel and for 4 weeks after leaving malarious area
     • Contraindicated in children under 8 years and pregnant women 1

  2. Atovaquone-proguanil (daily dosing)

     • Begin 1-2 days before entering malaria-endemic area
     • Continue daily during stay and for 7 days after return
     • Adult dose: 250 mg atovaquone/100 mg proguanil hydrochloride per day 2
     • Highly effective against drug-resistant strains of P. falciparum 3
     • Better gastrointestinal tolerability than chloroquine-proguanil 4

  3. Chloroquine plus emergency standby treatment

     • For those who cannot use mefloquine or doxycycline
     • Especially for pregnant women and children under 15 kg
     • Carry FansidarR (pyrimethamine-sulfadoxine) for emergency self-treatment 1

Special Considerations

Pregnant Women

• Recommended: Chloroquine (weekly)
• Pregnancy is not a contraindication to malaria prophylaxis with chloroquine
• Mefloquine and doxycycline should NOT be used during pregnancy 1

Children

• For children ≥15 kg: Same options as adults with adjusted dosing
• For children <15 kg: Chloroquine (mefloquine contraindicated)
• For children <8 years: Avoid doxycycline 1

Prevention of Relapses (P. vivax and P. ovale)

• Primaquine may be needed after travel to prevent relapses
• Administered during the last 2 weeks of the 4-week post-exposure prophylaxis period
• CRITICAL: G6PD deficiency must be ruled out before administering primaquine to prevent potentially life-threatening hemolysis 1, 5

Common Pitfalls and Caveats

1. Failure to match prophylaxis to resistance patterns: Always verify the current resistance patterns in the destination area before selecting medication.

2. Inadequate duration: Prophylaxis must be continued for the recommended duration after leaving the malarious area (4 weeks for most medications, 7 days for atovaquone-proguanil).

3. Self-treatment errors: Mefloquine should not be used for self-treatment due to frequent side effects, especially dizziness 1.

4. Overlooking G6PD testing: Always test for G6PD deficiency before prescribing primaquine to prevent potentially fatal hemolysis 5.

5. Drug interactions: Extreme caution is needed when using quinine to treat malaria in patients taking mefloquine prophylaxis due to similar cardiovascular and neurological toxicity profiles 1.

6. Ignoring contraindications: Mefloquine is contraindicated in patients with psychiatric disorders, epilepsy, or those requiring fine coordination (e.g., pilots) 1.

7. Overlooking P. vivax/P. ovale relapse risk: These species can cause relapses for up to 4 years after exposure 1.