friends don’t let friends take Lariam, but what about pregnant friends?

“Lariam” by Francesco Terzini, shared with cc license via Flickr

The New York Times reported on Monday’s announcement by the US Federal Drug Administration that mefloquine hydrochloride — aka Lariam — “must carry the so-called black box warning on its label because of the danger that the drug could cause serious neurological and psychiatric side effects, some of which can become permanent.” For those who don’t know, Lariam is often taken as prophylaxis against malaria.

In the decade I’ve traveled to malaria-endemic countries, I’ve never taken Lariam. Word on the street was that Lariam would make you have weird dreams (more like nightmares) and, for some people, hallucinations. What’s new about the news is the evidence that these side effects don’t necessarily stop when you stop taking Lariam, but instead can persist long after. (For the record, Jason Kerwin was way ahead of the curve on this one.)

Lariam is not the only anti-malarial prophylaxis one can take. When I travel to malaria-endemic countries (and am not pregnant) I always take Malarone, which has been shown in randomized double-blind trials to be as effective as Lariam as malarial prophylaxis, but to have fewer adverse effects. I always thought the travelers I met in malaria-endemic countries taking Lariam were a little odd, probably because of a pre-conceived bias I had based on what I already heard of Lariam. I wondered why they would take this drug that could potentially make them hallucinate in a place that is not their home? They could take Malarone, like me (but it is expensive). Or doxycycline, like some of my friends (but it makes people sensitive to the sun). Or something else.

In fact, because there are many options, I wondered why the news about Lariam even mattered — just take something else! One oft-cited upside to Lariam is that it’s taken weekly (instead of daily, like Malarone and Doxycycline). A friend also remarked on a Facebook posting of the NYT article, “Unfortunately [Lariam] is also the only anti-malarial safe (and effective) to take during pregnancy.” I wondered: is that true?

Malaria prevention during pregnancy is particularly important to me, as someone who has been pregnant in a malaria-endemic country and who fields questions from other potential travelers (and potentially pregnant travelers) about how to prevent getting a disease that puts an expectant mother’s life at risk (consequences of infection are more severe in non-immune women), as well as the life of her unborn child. From the World Health Organization (WHO):

Pregnant women are particularly vulnerable to malaria as pregnancy reduces a woman’s immunity to malaria, making her more susceptible to malaria infection and increasing the risk of illness, severe anaemia and death. For the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight – a leading cause of child mortality.

When I became pregnant, I stopped taking anti-malarials, exclusively wore long sleeves and pants, and never went out at dusk. It wasn’t ideal to take nothing, but my doctor said pregnancy was contraindicated with the anti-malarial I was taking and that I needed to quit. Since then I’ve wondered why there isn’t better prophylaxis for pregnant moms. Ward and colleagues describe the puzzle exactly in a 2007 article in THE LANCET Infectious Diseases:

Despite the clear need for safe and effective antimalarial drugs for use in pregnancy, the pharmaceutical industry is reluctant to develop drugs specifically for this indication, and in almost all cases in which a new drug is being developed, use in pregnancy is contraindicated.

The US Center for Disease Control and Prevention (CDC) recommends mefloquine (aka Lariam) for prophylaxis in pregnant women. Chloroquine has also been used in pregnant women, but has lost favor because of the rise of chloroquine-resistant strains of malaria. The CDC advises against pregnant women using Malarone, Doxycycline, and Primaquine.

So what does an expectant mother do if she plans to travel to a malaria-endemic country? Most docs I’ve interacted with simply say: don’t go. That advice is echoed by the CDC and the WHO. And, it isn’t just limited to the chance of catching malaria, but to other potential risks.

I wish I had more information. Ward et al. (2007) conclude their study by saying more research is needed:

Use of antimalarial drugs in pregnant women continues to be a problem in which the risks to the woman and fetus are not completely known. More information on the correct doses to be given to pregnant women is desperately needed. Large-scale trials and post-market surveillance systems to monitor drug safety in pregnancy are required.

Below is a list of some potentially useful resources. If haba na haba readers have any additional information, please share in the comments.

• Malaria prevention in short-term travelers (with information on pregnant women and children), by David O. Freedman, M.D., published in The New England Journal of Medicine in 2008
• Tips on Choosing the Right [anti-malarial] Drug for an Individual Traveler, by the CDC
• Advising on travel during pregnancy, by Natasha L Hezelgrave, Christopher J M Whitty, Andrew H Shennan, and Lucy C Chappell, published in the BMJ.