Considerations when choosing a drug for malaria prophylaxis:
Recommendations for drugs to prevent malaria differ by country of travel and can be found in the country-specific tables of the Yellow Book. Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that country.
No antimalarial drug is 100% protective and must be combined with the use of personal protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquito-free setting or using an insecticide-treated bednet).
For all medicines, also consider the possibility of drug-drug interactions with other medicines that the person might be taking as well as other medical contraindications, such as drug allergies.
When several different drugs are recommended for an area, the following table might help in the decision process.
Drug Reasons that might make you consider using this drug Reasons that might make you avoid using this drug
Atovaquone/Proguanil (Malarone)
Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
Some people prefer to take a daily medicine
Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks
Very well tolerated medicine – side effects uncommon
Pediatric tablets are available and may be more convenient
Cannot be used by women who are pregnant or breastfeeding a child less than 5 kg
Cannot be taken by people with severe renal impairment
Tends to be more expensive than some of the other options (especially for trips of long duration)
Some people (including children) would rather not take a medicine every day
Chloroquine
Some people would rather take medicine weekly
Good choice for long trips because it is taken only weekly
Some people are already taking hydroxychloroquine chronically for rheumatologic conditions. In those instances, they may not have to take an additional medicine
Can be used in all trimesters of pregnancy
Cannot be used in areas with chloroquine or mefloquine resistance
May exacerbate psoriasis
Some people would rather not take a weekly medication
For trips of short duration, some people would rather not take medication for 4 weeks after travel
Not a good choice for last-minute travelers because drug needs to be started 1-2 weeks prior to travel
Doxycycline
Some people prefer to take a daily medicine
Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
Tends to be the least expensive anti malarial
Some people are already taking doxycycline chronically for prevention of acne. In those instances, they do not have to take an additional medicine
Doxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
Cannot be used by pregnant women and children <8 years old
Some people would rather not take a medicine every day
For trips of short duration, some people would rather not take medication for 4 weeks after travel
Women prone to getting vaginal yeast infections when taking antibiotics may prefer taking a different medicine
Persons planning on considerable sun exposure may want to avoid the increased risk of sun sensitivity
Some people are concerned about the potential of getting an upset stomach from doxycycline
Mefloquine
(Lariam)
Some people would rather take medicine weekly
Good choice for long trips because it is taken only weekly
Can be used during pregnancy
Cannot be used in areas with mefloquine resistance
Cannot be used in patients with certain psychiatric conditions
Cannot be used in patients with a seizure disorder
Not recommended for persons with cardiac conduction abnormalities
Not a good choice for last-minute travelers because drug needs to be started at least 2 weeks prior to travel
Some people would rather not take a weekly medication
For trips of short duration, some people would rather not take medication for 4 weeks after travel
Primaquine
It is the most effective medicine for preventing P. vivax and so it is a good choice for travel to places with > 90% P. vivax
Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks
Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
Some people prefer to take a daily medicine
Cannot be used in patients with glucose-6-phosphatase dehydrogenase (G6PD) deficiency
Cannot be used in patients who have not been tested for G6PD deficiency
There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time primaquine is considered
Cannot be used by pregnant women
Cannot be used by women who are breastfeeding unless the infant has also been tested for G6PD deficiency
Some people (including children) would rather not take a medicine every day
Some people are concerned about the potential of getting an upset stomach from primaquine
