What medications are recommended for malaria prophylaxis?

Recommended Medications for Malaria Prophylaxis

Atovaquone-proguanil is the first-line medication recommended for malaria prophylaxis, especially in areas with chloroquine-resistant Plasmodium falciparum. 1

First-Line Options

Atovaquone-Proguanil

• Dosing: Daily dosing, starting 1-2 days before travel, continuing daily during travel, and for 7 days after leaving the malarious area 1
• Advantages:
  • Highly effective against drug-resistant strains of P. falciparum 2
  • Better tolerated than other antimalarials with fewer gastrointestinal adverse events than chloroquine plus proguanil and fewer neuropsychiatric adverse events than mefloquine 2
  • Shorter post-travel dosing period (7 days) compared to other options (4 weeks) 1, 2
• Weight-based dosing for children 3:

  • 45 kg: One tablet daily

  • 30-45 kg: 3/4 tablet daily
  • 20-30 kg: 1/2 tablet daily
  • <20 kg: Limited experience

Doxycycline

• Dosing: Daily dosing, starting 1-2 days before travel, continuing daily during travel, and for 4 weeks after leaving the malarious area 1
• Advantages: Effective against mefloquine-resistant falciparum malaria in East Asia 4
• Precautions:
  • Should be taken with meals to minimize gastrointestinal side effects 1
  • Take in the evening to reduce photosensitivity 1
  • Contraindicated in pregnant women and children under 8 years 1

Second-Line Options

Mefloquine

• Dosing: Weekly dosing, 250 mg adult dose once weekly, starting 1-2 weeks before travel, continuing weekly during travel, and for 4 weeks after leaving the malarious area 1
• Contraindications:
  • Psychiatric disorders, epilepsy, and tasks requiring fine coordination 1
  • History of convulsions or serious psychiatric disorder 4
  • Not suitable for those with liver impairment 4
• Side effects: Neuropsychiatric effects including anxiety, depression, sleep disturbances, nightmares, hallucinations, and in rare cases, psychotic attacks or convulsions 4

Chloroquine

• Dosing: Weekly dosing, starting 1-2 weeks before travel, continuing weekly during travel, and for 4 weeks after leaving the malarious area 1
• Limitations: Only effective in areas without chloroquine resistance 1

Special Populations

Pregnant Women

• Should avoid travel to areas with chloroquine-resistant P. falciparum if possible 1
• Chloroquine and proguanil have a long history of safe use during pregnancy 1
• Mefloquine can be used in second and third trimesters 1
• Doxycycline is contraindicated 1, 5

Children

• Children ≥15 kg should receive the same options as adults with adjusted dosing 1
• Children <15 kg should receive chloroquine, as mefloquine is contraindicated in this age group 1
• Doxycycline is contraindicated in children under 8 years 1, 5

Personal Protective Measures

In addition to chemoprophylaxis, the following measures are essential:

• Use DEET-containing insect repellent on exposed skin 1
• Wear long-sleeved clothing treated with permethrin 1
• Use mosquito nets at night 1
• Remain in well-screened areas, especially between dusk and dawn 1

Post-Travel Considerations

• Continue prophylaxis for the recommended duration after leaving the malarious area:
  • 4 weeks for mefloquine, doxycycline, and chloroquine
  • 7 days for atovaquone-proguanil 1
• Seek medical attention immediately if fever develops within 3 months of return 1
• Inform healthcare providers of travel history 1

Common Pitfalls and Caveats

1. Poor compliance: Most malaria deaths occur in those who don't fully comply with prophylaxis regimens 4
2. Breakthrough infections: Can occur with all regimens, so travelers should remain vigilant for symptoms 1
3. Inadequate protection: No antimalarial guarantees complete protection; personal protective measures are essential 5
4. Stopping too soon: Failure to continue prophylaxis for the recommended duration after leaving endemic areas 1
5. Ignoring symptoms: Delay in seeking medical attention for fever after return from endemic areas 1

Atovaquone-proguanil has demonstrated superior efficacy and tolerability compared to other options, making it the preferred first-line choice for most travelers to areas with chloroquine-resistant malaria, with doxycycline as an excellent alternative when atovaquone-proguanil is contraindicated or not tolerated.