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

31 July 2013

“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.

25 Comments leave one →
  1. abedgell permalink
    31 July 2013 9:56 am

    Preventing malaria this year has been particularly taxing for travelers due to a shortage of doxycycline. In June, it cost over $200 for a 1 month supply versus the $10 I paid in 2010. But the good news is that there is now a generic form of Malarone on the market. I got 2 months worth for only $20. This compares to almost $10 per pill in 2010. I’ve never taken larium/mef due to the side effects, but had similar problems after taking Doxy for an extended period- aka lucid dreams. Plus, in my experience, doxy causes all sorts of other problems like fatigue, upset stomach, severe acid reflux, and increased sensitivity to side effects from other scripts / alcohol. Now I only take Malarone. Thanks for the post. I wasn’t aware of the prejudice against pregnant women in the prophylaxis development community.

  2. jimi permalink
    31 July 2013 10:30 am

    fwiw – I recall (pre-generic Malarone days) some (especially student) insurance plans only covered doxy/lariam, and the gut issues for some w/doxy was the reason folks I traveled w/ were on lariam. That switched for me at OSU between my 2005/2006 trips (I did not have Malarone as an option the first, did the 2nd).

  3. 31 July 2013 11:44 am

    Personally, I couldn’t get malarone covered and it was too expensive for me to pay out of pocket. Doxy was cheap when I looked, but I didn’t like that doxy had sun sensitivity (and to be more honest, that it lost effectiveness if you drank alcohol). I may have underestimated the risks of taking lariam, but I had the most amazing, vivid dreams while I was doing fieldwork. They weren’t negative and nothing persisted. Maybe I was lucky. Thanks @abedgell, I had no idea that there was a generic malarone.

  4. 31 July 2013 9:51 pm

    So, a reader forwarded me a link to a published paper of his that shows mefloquine (Lariam) could have negative effects on fetal development.

    Sorry, pregnant friends!

  5. 1 August 2013 9:06 am

    care of Wikipedia’s Malarone page, more information on the availability of generic Malarone:

    The combination of atovaquone and proguanil to treat malaria was patented by Glaxo Wellcome in 1999, with patent protection due to expire in 2013.[8] Glenmark Generics has already had a generic formulation win FDA approval in 2011.[9] In February 2013, the United Kingdom High Court revoked Glaxo’s patent on account of obviousness, clearing the way for generic versions to be sold there.[10]

  6. 29 January 2014 4:22 am

    In order to achieve pregnancy, you required to know what’s inside your body which enables you to have a baby. The more you know their facts and functions, the easier you overcome those challenges to conceive or become pregnant.

  7. 10 December 2014 11:23 am

    I work on malaria programs, and traveled to malarial countries while pregnant. I am totally with you on refusing to take Larium/mefloquine. I have never taken it, and would certainly not take it while pregnant.
    I don’t think anything else is approved for first trimester use in pregnancy outside of quinine as a curative, but women living in endemic areas are advised to take multiple routine doses of Fansidar/SP at one month intervals to treat any undetected malaria infection:
    It is not officially recommended for pregnant travelers, but it seems to me that there is good safety data available on the use of SP in pregnancy so I personally would feel much more comfortable with this option.
    I should footnote this all by saying I’m not a clinician and have no clinical knowledge!

  8. Ali McLegg permalink
    26 January 2015 11:09 am

    An advisor from the Motherisk program (Toronto, Canada) suggested to me (if I have understood correctly) that the reason Malarone is not recommended for pregnant women is simply that there haven’t been any studies done to conclude that it is safe. (What drug company wants to risk doing a study on pregnant women?!). I was told that there were limited studies (3 of them, with 26, 81, and 149 participants, respectively), in which no increased risk from taking malarone was shown. But because these are small studies, no real conclusion can be drawn.

    I’m torn between taking the malarone and just trying to avoid being bitten, which seems like a project that is sure to fail…

    • Sanna from Sweden permalink
      28 February 2015 7:26 am

      Im pregnant in week 25 and will soon go to Mozambique. I have talked to plenty of doctors in Sweden (most of them say – stay home or take lariam but two of them now say no to lariam, take malarone! I feel torned… I dont want to risk my babys health, and I dont want to have Malaria… Help and advice – anyone?

      • Sarah permalink
        21 April 2015 8:21 pm

        Hi Sanna
        Did you end up taking Malarone? I’m in a similar situation and my doctor recommended it.

      • Sanna from Sweden permalink
        26 April 2015 1:46 pm

        I did! I’m back home and took it for 3 weeks in total, felt fine and no side effects during the time I took them… Well, the baby is not out yet but hopefully it’s a wealthy one in 10 weeks 🙂

      • Sarah permalink
        26 April 2015 6:11 pm

        Thanks so much Sanna for your reply! Hope you’re feeling well. Have an easy labor and delivery!

      • Sanna from Sweden permalink
        26 April 2015 1:50 pm

        Ooops, not wealthy – healthy!! Wealthy would be nice as well 😀

      • 26 April 2015 6:19 pm

        Thanks, Sanna from Sweden, for sharing your experience. Wishing you a safe and happy delivery.

  9. Anon permalink
    11 May 2015 2:16 pm

    Thanks for the article. Having taken Lariam more than once I can safely say I would rather get malaria a hundred times over than have to go through that again. I know plenty of people who have taken it as well, at bare minimum everyone has intense side-effects, night terrors, feeling like walking through a fog. I can’t believe they would recommend that for pregnant women, should be taken off the market entirely.
    I’ll go with Malarone next time, but worried because I’ll have to take it for longer than 12 weeks…

    • Sarah permalink
      11 May 2015 3:52 pm

      I just took malarone. No side effects…just take with food to avoid dizziness.

  10. 5 June 2015 3:49 am

    I was taking Lariam at the same time I fell pregnant with my third child. I took three doses. He was diagnosed with permanent hearing loss at birth. Hearing loss has never been an issue on either sides of the family. I love him to death and hearing loss is just a part of who he is but I’ll forever hold it in the back of my mind!

  11. Stephanie permalink
    8 December 2015 7:40 pm

    I took Larium for a month in 2001 and 5 months in 2004 with no noticeable side effects. Who knows? Maybe I am lucky. I recently found out I was pregnant and will be traveling to a malarial region. Does anyone know any new research (good or bad) about Larium and pregnancy?

  12. 26 December 2015 2:42 pm

    hello everybody,
    do you have any recommendations for breastfeeding women? any experience? would be happy for any advice…my baby is 6 month and we just moved to Ghana

  13. 10 May 2016 7:43 pm

    I took Larium and fell unexpectedly pregnant 8 weeks after finishing the course. I was told it would be fine by my GP. My baby, who is now almost 22yrs has suffered ill mental health for most of his life (including, similar to amandaoj’s baby, hearing impediments). As a child and adult he has displayed similar symptoms to the many soldiers (and others) that have used the drug. We have a daughter who is very balanced and easy going, so its hopefully not us! We love our son unconditionally, but no amount of love seems to be easing his suffering.
    Although medications effect us all differently I would advise ‘Do not be tempted to use this drug’!

  14. janice/lynne permalink
    14 December 2018 11:40 am

    I have a family member with schitzophrenia and anxiety/depression. I’m wondering if this drug or LSD can be removed from the body. I’d know if this was a cause if I knew if it would be something a teen might take. Does it cause a high? Or could it have been slipped to her like in a drink by someone? I’m looking for a reason for the schitzophrenia other than hereditary as that doesn’t seem to be the cause. If I could identify a med that causes these symptoms and it was available to teens/something they may be taking now or then, then I could research to find out how to get it OUT of the system.
    Thank you kindly.

  15. janice/lynne permalink
    14 December 2018 11:43 am

    On another subject, I take doxyclycine for bronchitis. Is this a dangerous drug? Thank you.


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