Daily bleg: anti-malarials

Now, I like to give out inexpert, uninformed medical advice as much as the next guy. But I have more and more research assistants in the field these days, and it would be really fantastic if none of them fell deathly ill because of, well, my research papers.

Here’s the question. We have at least two perfectly common anti-malarial options–doxycycline and mefloquine–each of which cost a few cents each. They’ve been around a while, so we know what to expect. Doxy: sun sensitivity in the occasional case, and no milk in your coffee that morning (which is a tragedy). Mefloquine: crazy dreams among a few (including me).

Along comes a fancy-pants new drug, Malarone. It costs $6 a pill, with insurance, and has to be taken every day. Why would I pay 120 times more than the generic? Is it 10 times as effective? 1.2 times? Just as effective? As far as I can tell, there aren’t studies on the matter.

So why are the Yale travel nurses defaulting to Malarone? The minute I suggested that my preferred drug, Doxy, was an alternative, they agreed and wrote out the prescription.

Theories:

1. Human folly: new, more expensive things must be better;

2. Because it’s new, resistance is nil, so Malarone is by definition better;

3. Very effective marketing; and

4. Doctors don’t want to advise people to explore whether they’re among the 1 in 20 who experience a side effect from the generics.

On the con side: there are no long term studies on the effects of Malarone. So it could turn your grandchildren into mutants. Oh, and we get robbed blind at the rate of $6 a day.

24 thoughts on “Daily bleg: anti-malarials

  1. The fact that doxy interferes with birth control is important. Another thing to remember is that both oral birth control and oral malaria prophylaxis will be less effective when your digestive system is having trouble absorbing nutrients, pills, etc, which is what is going on much of the time that you have diarrhea. And diarrhea is a common occurrence in areas where you might also need prophylaxis. All the more reason to be vigilant and use other preventative methods, like barriers (condoms, or mosquito nets and clothing, which ever is applicable).

    @talesfromethehood: I have a problem with prophylaxis non-believers. If you have the money and/or insurance to take prophylaxis, you are in a position of great privilege compared to those all around the world who do not, and who die at alarming rates from malaria. Yes, unlike these people, you also have the money, insurance, and privilege to access treatment should you come down with malaria. Still I think it is irresponsible not to use a prophylaxis if you have access to it: irresponsible to yourself and to the greater community. (Similarly, I think those with means who do not vaccinate themselves or their children are irresponsible.)

  2. Another interesting thing about Doxycycline is that it an antibiotic. (drugs.com: used to treat many different bacterial infections, such as urinary tract infections, acne, gonorrhea, and chlamydia, and others).

    So perhaps while you’re on Doxycycline you may prevent some other nasty tropical infections, but on the other hand it could have an effect on your antibiotic use if you do get sick from something else.

    Alternatively you can choose not to take any malaria prophylaxis and instead bring a malaria rapid diagnostic test plus a treatment of an Artemisinin based combination therapy (Like Coartem), in case you test positive.

  3. Personally, doxy is my new favourite. Just completed 100 days on it, no malaria, and nothing else either, for that matter, except a short, light, common cold. Yes, I take heavy doses of pro-biotic supplements, and that is kind of expensive.

    On the other hand, in 2005 I took malarone for a 30 day trip to West Africa, got malaria, and had a non-functional digestive system for over two years. I still took the same pro-biotic supplements…

    Doxy is way cheaper, you take it every day, just as malarone, and, just as malarone, it goes best with our dinner.

    At last, as the number of people I know who get crazy from mefloquine significantly – without data mining – outnumber the very few cases I know who don’t get crazy, I’ll definately stay away fomr that drug!

  4. I’m willing to bet that most of the DUH nurses haven’t ever taken anti-malarials, so they go with #2 or #3. Certainly that was my experience at Yale, and it’s the same at my current university. I sometimes have to talk them into mefloquine, but they’re usually alarmingly willing to defer to my wishes on anti-malarials (and everything else). I think they figure that since my vaccination record is so extensive, I must know that of which I speak.

    I love those crazy Mefloquine dreams, but not as much as I love the fact that you can buy it on the cheap without a prescription in any good pharmacy in central Africa.

  5. I’ve taken Mefloquine in Kenya and had a terrible time with the dreams — and I think some daytime disorientation. I’ll never touch the stuff again.

    I’ve taken doxy in Nigeria and came down with malaria.

    For now I’m sticking with Malarone. Or more often–since I used to live in Africa and couldn’t take pills for such a long period– nothing.

  6. I spent six months on Mefloquine in Sudan in 2007; the weird dreams weren’t necessarily “crazy”, but it affects everyone differently. Apparently taking a multivitamin with lots of B12 mitigates the negative effects (and liver damage) – the Canadian Forces gave us multivitamins designed for pregnant women.

    By contrast, the only people I knew who got malaria while over there were using Malarone, but each strain of malaria is resistant to different medications. When all is said and done, I would recommend Mefloquine, but not for more than six months at a time (actually, no malarial medication should be taken for longer). Our military doctors suggested that there are so many strains of malaria resistant to doxycycline that it’s essentially not worth taking.

    Start taking the Mefloquine three weeks before you leave, that way if it affects you particularly badly you can switch to something else. I did find it a bit unnerving that one of the listed potential side-effects was “suicide”.

  7. Omair and Nathan: my wife has worked in Yale-New Haven hospital.

    Yale has a very progressive policy with respect to pharm reps; they're not allowed in the hospital to give gifts or lunches like they are at many other hospitals.

    They of course still advertise in medical journals &c, and try to get docs to come to dinners outside of work, but I think that Yale's policies at least merit consideration as arguing against the "in bed with big pharma" hypothesis.

  8. I’ve never taken Larium, but it scares the crap out of me. Several friends reported horrendous, vivid, scar-you-for-life nightmares.

    Two people I know decided not to take anti-malarials at all (one in Ghana, the other in Burma) after hearing too many side effects stories. Both of them got malaria, but, to be honest, their “I had malaria” stories aren’t anywhere near as bad as the “I dreamt I killed all my friends” Larium tales.

  9. Ditto with what people above have said about the downsides of mefloquine. I’ve known people who have had very bad side effects. And I’m told many countries don’t allow their nationals to take it.

    Doxy has some obvious negative side effects as well.

    So maybe nurses are just hoping malarone is better on that front? I’m not sure there is a winning choice for everybody.

  10. Someone’s got to say this: I’m a malaria prophylaxis non-believer. As are most of those in my close aid-work circle. This despite…

    – repeated, lengthy visits to the border of Thailand/Myanmar (including wet season) in 1991.
    – lived in the Mekong Delta (1993-4)
    – repeated visits to rural Cambodia (1996-present)
    – Repeated visits to rural Ghana, Mozambique, Ginuea-Conakry and Angola (1998-2004)
    – Lived in Hanoi, but with frequent travel to Cao Bang, Ha Giang, and Quang Ngai provinces. (2001-4)

    Took prophylaxis only once (doxy in Ghana). Never had malaria…

  11. I have to agree with Omair. I have worked with many doctors, and a number of drug sales people, and have come to realize the medical industry is very much in bed with the pharmaceuticals. Doctors are after all people. Don’t assume they are actually maximizing over your health.

  12. And I’ll add theory #7. The makers of Malarone have made a substantial contribution to Yale’s hospital, and so the nurses have been instructed to push their drug.

  13. A fellow traveler got malaria while on Doxy in Ghana. I took Lariam a few years ago, and hated the side-effects – not just the bad dreams, but the the neuropathy in my fingers. My fellow traveler had hallucinations.

    I have nothing to complain about with Malarone, but then, I didn’t have to pay for the whole thing out of pocket.

  14. New and unproven drugs seem to be attractive to both doctors and pharmaceutical companies. A lot of the increase in prescription drug costs in recent years can be attributed to a shift from older, cheaper drugs to newer, more expensive drugs that are no more effective.

    http://www.bmj.com/cgi/content/extract/331/7520/815

  15. I’d add 5) people will be angry at you in this country if you don’t prescribe them “the best”

    Then I’d go for an even combo os 3,4, and 5.

    I had an awful experience at the Johns Hopkins travel clinic a few weeks ago; the doctor there got visibly angry when we asked a question whether an antimalarial would be necessary on our trip to Panama. (We discovered later that about 1 person dies of malaria per year in Panama).

    This suggests to me reason #6) lawsuit avoidance. If a doctor’s not seen as prescribing “the best” medicine, they may open themselves up to legal action.

  16. I should have added that the malaria parasite in many places in Asia and Africa have developed resistance to mefloquine. This explains why some commenters found it failed when used as a preventative.

  17. Why not doxy: it can decrease the effectiveness of birth control. This is only relevant for at most half the population, but something important.

    Why not lariam/mefloquine: psychotic/intensely depressive episodes are not actually that uncommon; I know two women personally who experienced serious psychological side-effects, one of whom was briefly hospitalized as a consequence.

    So while the risk may be low overall, a bad draw can be pretty bad. That said, I took mefloquine for a year and a half, got malaria twice while on it (in Kenya), and have used malarone successfully ever since.

  18. I got a 3 month course of Malarone for a $50 copay when I used it. It depends on your insurance. To avoid the side effects of the other two, I was happy to pay. Had it actually been $6 a day, I probably would have tried one of the others.

  19. Chris –
    there is both the individual and social perspective to take into acct in deciding which malaria drug to take.
    From your individual perspective, you’d be happy taking the cheapest drug THAT works against the relevant parasite.
    But from a social (and therefore health policy) perspective, we’d prefer individuals take drugs that don’t accelerate the development of resistance to the few drugs we have to combat malaria. Mefloquine by itself is NOT recommended for this reason – rather it is recommended in a combined form with a second malaria drug (often sulfa-doxine pyremethamine – IF that works in the locality under consideration). Usually the combined drug costs more – which is one reason why, barring public subsidies – people make individual decisions (take cheap mono-therapy) that do harm to society at large (reduce time the drug works against the disease).

  20. I agree with naman. On top of that, I like to think that the relatively smaller dose of drug I’m getting daily is probably better for me than having a big clod slowly breaking down over the course of the week. It’s totally unscientific and probably ill-informed, but I do feel better when on Malarone than when I took doxy.
    Now… back to your business class discussion – is $6 a day really so criminally high? It probably is if you have to take it for years and years but most people I know who are living or working in the tropics for more than a couple of months, just stop taking anything and smash their systems with doxy if they are feeling ill. For a 2 week stint, $6 malarones don’t seem like such a hardship.

  21. I used Malarone recently when I went to Mozambique. I had heard of the alternatives but took the advice of my doctor/nurse. In any case, I paid a token amount for a two week course – more like $8 for the entire prescription. This was in the UK, on the NHS however…whilst my friends in South Africa used either of the options above, but also paid quite a lot more for their prescriptions.

    From a consumer point of view, you would expect that the nurses are aware of the evidence. From this perspective, then, it’s 2 or 3. Perhaps the nurses aren’t as well informed as they ought to be.

  22. There’s little data on prophylactic efficacy for most antimalarials except for the occasional case report – mefloquine treatment resistance in SE Asia and the Amazon region would lead me to avoid it there.

    I think #4 is the primary reason malarone is so often prescribed. I don’t prefer it because it is expensive and you have to take it daily. On the other hand you only need to start malarone 1-2 days prior to travel vs 1 week, and continue it for 1 week post-travel vs 4 weeks.

  23. There’s a lot of scare talk about doxy, but mostly among people who expect to be taking it for a reasonably long time (1-2 years, with breaks during the dry season). The general concern is about taking a general antibiotic, despite the fact that the alternative is much worse!

    That said, it does tear up some people’s digestive track (it destroys the good bacteria as well) so it’s usually recommended that you take some sort of probiotic supplement.

    I took it for two years with no problems (aside from getting Malaria twice anyway). People often don’t know you need take it on a full stomach (take it for lunch, breakfast is too light).