Which Malaria Prophylactic Should you Take?

There is no vaccine for malaria, but you can take prophylactics. The reason a vaccine has not been developed is largely due to the life-cycle of the protist that causes the disease.

When an infected mosquito bites you, the protist enters your bloodstream and makes its way inside of your red blood cells. Because the protist does its damage from inside the cell, a vaccine is exceptionally difficult to formulate (just ask Bill Gates). Each cycle of chills, fever, and convulsion begins when millions of your red blood cells explode and the protist begins looking for new real estate.

Best to not get it in the first place, right?

There are five malaria prophylactics that are prescribed for travel in areas in which malaria is endemic, but most people end up taking one of the three listed below. They all have their pros and cons. Remember, you should always consult a doctor at a travel health clinic before deciding on a malaria prophylactic. Depending on your destination, there may be specific strains of malaria and certain prophylactics may be more appropriate than others (have a look at this table from the CDC).

Also, keep in mind that this list is not comprehensive – it displays the most commonly prescribed prophylactics, but not all of them. For more information on additional prophylactics as well as the ones listed below, have a look at the CDC’s malaria prophylactics page.

Mefloquine (Lariam)

Mefloquine, popularly known as Lariam, was once considered the most effective prophylactic and in some cases, treatment option, for multiple strains of malaria. Its stock has fallen in recent years for many reasons. For one, it is no longer proving as effective in prevention or treatment and there are now strains that are becoming mefloquine-resistant.

In addition, Lariam has notorious side effects, some of which I have personally experienced. According to the British Medical Journal, 25% of people taking Lariam experience central nervous system side effects. 25%!!!! These side effects may include: severe depression, anxiety, paranoia, aggression, nightmares, insomnia, and seizures. Personally, I have experienced high levels of anxiety and some of the worst nightmares I have ever had on Lariam. I have not taken the drug since. For more on the psychological side effects of Lariam, see this article from the New York Times and have a look at the video below.

Lariam, however, is a once-a-week pill and is thus far less expensive than Malarone (it must be said, however, that you also need to begin taking Lariam 2 weeks before your trip and you must take it for 4 weeks after you have returned). If you are not susceptible to the above side effects, it may be the right choice for you, depending on your destination and the strains of malaria that are found there. Again, this is an important choice and one that you should make with a doctor.

Lariam Update 8/15/13: the FDA has authorized label changes for mefloquine, adding a boxed warning, which is the most serious warning for side effects. Read about the label changes here. You should discuss these potential side effects with your travel health doctor before agreeing to take mefloquine for your malaria prophylaxis.

Atovaquone and Proguanil Hydrochloride (Malarone)

Malarone is taken daily, starting 1-2 days before traveling, then each day of your trip, and for 7 days after you return. In addition to being effective in preventing malaria, there are also fewer reported side effects. Finally, in many areas, malarone has shown to be the most effective prophylactic option (it’s considered 98% effective as a prophylactic against p. falciparum, the most virulent strain of malaria).

Malarone, however, is a daily pill, and it is expensive. If you are getting it from a pharmacy before you travel, expect to pay up to $4 PER TABLET! You can find it cheaper in developing world pharmacies, but even there it is far more expensive than the other options.

Doxycycline is an antibiotic, commonly used to treat many different infections. It has also proven effective in preventing malaria. It is a daily pill (start 1-2 days before trip, every day during trip and then for 4 weeks after), but it is incredibly cheap. You can find generic doxy for $.40 a tablet, before you leave, and even cheaper in developing world pharmacies.

Doxy does have a few side effects, however. One of them is increased sensitivity to sunlight. Long-term doxy use may cause permanently sensitive and thin skin. It is also an antibiotic; long-term antibiotic use is generally not good for your body because positive bacteria are affected (see our article on taking probiotics for info on restoring beneficial bacteria). It has also been known to irritate the esophagus (I have experienced this and it’s awful) if you lay down after taking it – it can cause symptoms of acid reflux disease. When taking doxy, it is recommended that you stay upright for at least 30 minutes after taking a tablet.

Read about my experience with acid-reflux and doxycycline.

My Choice

I have taken both Lariam and Doxy. I have come down with malaria while taking both (although, when I was on Doxy I missed several doses). I will never take Lariam again merely because of the psychological side effects. Doxy gave me severe side effects as well. I will take malarone on short trips. On longer trips, I will not take a prophylactic (I travel primarily in West Africa). I will take every measure possible to avoid bites, and I will carry Coartem at all times, a powerful treatment option for p. falciparum, the most common strain of malaria found in West Africa, which I mention in this article. Remember, this is my choice. Your travel health decisions should be made between you and your doctor.

As stated in the article titled Should you Take Malaria Prophylactics?, there are different factors to consider when choosing a medication in addition to cost and side effects, such as your destination, and length of travel. Regardless, it is always wise to visit a travel health clinic and consult a doctor before taking a trip to a place where malaria is endemic. You may have allergies to certain medications or you may be taking medication that has contraindications with one of the above prophylactics.

Please let us know if you have taken any of these medications in the comments below. What was your experience?