What is the most effective and safest prophylactic anti-malarial for non-immune adults and children travelling to regions with Plasmodium falciparum resistance to chloroquine?
Atovaquone-proguanil and doxycycline were well tolerated by most
travellers, and they were less likely than mefloquine to cause neuropsychiatric
adverse events. Chloroquine-proguanil caused more
gastrointestinal adverse events than other chemoprophylaxis. In
other respects, the common unwanted effects of currently available
drugs were similar. There was no evidence from head-to-head
comparisons to support primaquine use as primary prophylaxis
for travellers. The choice of whether to prescribe atovaquoneproguanil
or doxycycline (or exceptionally, mefloquine) should be
made by health practitioners by taking into account additional factors
such as cost, known contraindications to any of the drugs in
question (eg, pregnancy, breastfeeding, age), known rare serious
adverse events, previous use of the drugs, possible drug–drug
interactions, ease of administration, travel itinerary and the additional
protection that may be afforded by doxycycline against other
infections, besides malaria.
The body of evidence was small, and the quality of evidence
ranged from very low to moderate. Except for 2 trials, all the studies
in this review were funded wholly or in part by pharmaceutical
companies. As well as the 8 trials, there were also 22 published
case reports of deaths, including five suicides, associated with
mefloquine use at normal dosages. No other currently used drugs
were reported as causing death at normal dosages.
Malaria infects 10,000 to 30,000 international travellers each
year. It can be prevented through anti-mosquito measures and
drug prophylaxis. However, anti-malarial drugs have adverse effects
which are sometimes serious.