B. Atovaquone + proguanil – Explanation
In certain parts of South-East Asia there is widespread chloroquine resistance. Chemoprophylaxis
using atovaquone + proguanil (Malarone), mefloquine (Lariam) or doxycycline is therefore
recommended. Mefloquine should be avoided in this patient due to his history of epilepsy.
Malaria: prophylaxis
There are around 1,500-2,000 cases each year of malaria in patients returning from endemic
countries. The majority of these cases (around 75%) are caused by the potentially fatal Plasmodium
falciparum protozoa. The majority of patients who develop malaria did not take prophylaxis. It should
also be remembered that UK citizens who originate from malaria endemic areas quickly lose their
innate immunity.
Up-to-date charts with recommended regimes for malarial zones should be consulted prior to
prescribing
| Drug | Side-effects + notes | Time to begin before travel | Time to end after travel |
| Atovaquone + proguanil (Malarone) |
GI upset | 1 – 2 days | 7 days |
| Chloroquine | Headache
Contraindicated in epilepsy |
1 week | 4 weeks |
| Doxycycline | Photosensitivity Oesophagitis |
1 – 2 days | 4 weeks |
| Mefloquine (Lariam) | Dizziness
Neuropsychiatric disturbance |
2 – 3 weeks | 4 weeks |
| Proguanil (Paludrine) | 1 week | 4 weeks | |
| Proguanil + chloroquine | See above | 1 week | 4 weeks |
Pregnant women should be advised to avoid travelling to regions where malaria is endemic.
Diagnosis can also be difficult as parasites may not be detectable in the blood film due to placental
sequestration. However, if travel cannot be avoided:
- chloroquine can be taken
- proguanil: folate supplementation (5mg od) should be given
- Malarone (atovaquone + proguanil): the BNF advises to avoid these drugs unless essential. If
taken then folate supplementation should be given - mefloquine: caution advised
- doxycycline is contraindicated
It is again advisable to avoid travel to malaria endemic regions with children if avoidable. However, if
travel is essential then children should take malarial prophylaxis as they are more at risk of serious
complications.
- diethyltoluamide (DEET) 20-50% can be used in children over 2 months of age
- doxycycline is only licensed in the UK for children over the age of 12 years
