What are the recommended medications for malaria prophylaxis?

Recommended Medications for Malaria Prophylaxis

Mefloquine is the first-line medication for malaria prophylaxis, particularly in regions with chloroquine-resistant Plasmodium falciparum, with a simpler post-exposure regimen requiring only two tablets after the end of exposure. 1

Prophylactic Medication Options

First-line Options:

1. Mefloquine

   • Dosage: 250 mg once weekly for adults 2
   • Schedule: Begin 1 week before travel, continue weekly during travel, and for 4 weeks after leaving endemic area 1
   • Advantages: Effective against chloroquine-resistant P. falciparum 3
   • Contraindications: History of psychiatric disorders, epilepsy, or conditions requiring fine coordination 1
   • Side effects: Neuropsychiatric effects including anxiety, depression, sleep disturbances, nightmares, and hallucinations (usually occur early in treatment) 3

2. Doxycycline

   • Dosage: Daily dosing 1
   • Schedule: Begin 1-2 days before travel, continue daily during travel and for 4 weeks after leaving endemic area 1
   • Advantages: Alternative for those who cannot take mefloquine; effective against mefloquine-resistant strains in East Asia 3
   • Contraindications: Children under 8 years, pregnant women 1
   • Side effects: Photosensitivity, gastrointestinal upset 4

3. Chloroquine

   • Dosage: 300 mg base weekly 3
   • Schedule: Begin 1-2 weeks before travel, continue weekly during travel and for 4 weeks after leaving endemic area 1
   • Use: Only in areas without chloroquine-resistant P. falciparum 3
   • Side effects: Generally well-tolerated; rare serious side effects; minor ones include mouth ulcers, GI upset, skin eruptions 3

4. Atovaquone-proguanil

   • Advantages: Shorter post-exposure prophylaxis (7 days) 5
   • Efficacy: Highly effective against drug-resistant strains of P. falciparum 5
   • Tolerability: Better tolerated than chloroquine plus proguanil (fewer GI effects) and mefloquine (fewer neuropsychiatric effects) 5

Combination Approaches:

• Chloroquine + Proguanil: For areas with limited to moderate chloroquine resistance 3
  • Chloroquine 300 mg base weekly + Proguanil 200 mg daily
  • Less effective than mefloquine but fewer neuropsychiatric side effects 3

Regional Considerations

1. Areas without chloroquine resistance:

   • Chloroquine alone is recommended 3

2. Areas with chloroquine-resistant P. falciparum:

   • Mefloquine is first-line 3
   • Alternatives: doxycycline or atovaquone-proguanil 1, 5

3. Areas with mefloquine-resistant P. falciparum (parts of East Asia):

   • Doxycycline is recommended 3

Special Populations

1. Pregnant women:

   • Chloroquine is safe during pregnancy 1
   • Mefloquine and doxycycline should NOT be used during pregnancy 1

2. Children:

   • Doxycycline: Avoid in children <8 years 1
   • Mefloquine: Contraindicated in children <15 kg 1
   • Chloroquine: Recommended for children <15 kg 1

Critical Considerations

• Compliance: Most malaria deaths occur in those who do not fully comply with prophylaxis regimens 3
• Timing: Start prophylaxis before travel (1-2 weeks for most medications, 1-2 days for doxycycline) 3
• Duration: Continue for 4 weeks after leaving endemic areas (except atovaquone-proguanil which requires only 7 days) 1, 5
• Resistance patterns: Verify current resistance patterns in the destination area before selecting medication 1
• G6PD testing: Required before prescribing primaquine to prevent potentially fatal hemolysis 1

Non-Pharmacological Prevention

• Use DEET-containing insect repellent on exposed skin
• Sleep under mosquito nets
• Wear clothing that covers most of the body
• Use pyrethrum-containing flying-insect spray in living/sleeping areas
• Apply permethrin (Permanone) to clothing 1

Common Pitfalls

1. Inadequate duration of prophylaxis: Failure to continue medication for the recommended period after leaving endemic areas
2. Poor compliance: Taking medication irregularly or stopping prematurely
3. Inappropriate medication selection: Not matching prophylaxis to regional resistance patterns
4. Overlooking G6PD testing: When primaquine is needed for P. vivax/P. ovale relapse prevention
5. Ignoring drug interactions: Particularly with mefloquine and other medications

Remember that no antimalarial prophylaxis regimen is 100% effective, and personal protective measures against mosquito bites remain essential components of malaria prevention.