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MEFLOQUINE ALTERNATIVES If you were

MEFLOQUINE ALTERNATIVES

If you were watching the Fifth Estate on CBC last night, you may have seen the documentary about Canadian soldiers' use of the anti-malarial mefloquine (also suspected as possibly causative in the recent "Green Beret" murders at Fort Bragg by soldiers coming off Afghan deployments). If you looked really closely, you'd even have seen yours truly in the "thank you" credits, even though I don't think I did much more than say "no" on behalf of the CF... in a nice way, of course.

The big question the documentary leaves unanswered is the only one that's important to me personally... what are the alternatives? Yes, it's accepted mefloquine can cause vivid nightmares or even personality change in a very small number of users (it is, after all, a quinine derivative). There is no doubt, however, that it's also the most effective drug for use by soldiers against malaria, and if it (or one of the alternatives) wasn't taken, soldiers would certainly sicken and die. So armies have to prescribe an anti-malarial in many parts of the world. They have 4 choices:

Mefloquine: extremely effective, can be used for up to a year, only needs to be taken weekly. Side effects include nightmares, personality change.
Chloroquine: an older treatment... due to emergence of chloroquine-resistant malaria strains, no longer very effective. No limit on length of time usable, but must be taken daily.
Doxycycline: effective, can be used for up to six months in theatre, but must be taken daily. Major side effect is increased sensitivity to sunlight... often itself a problem for soldiers.
Malarone: a newly-licensed drug (the FDA approved it in 2000), which has tested well but is only now being widely prescribed. Apparently highly effective, but due to the relative lack of information on its effects, is currently generally limited to a maximum of one month's continuous usage in malaria zones.

So if you're a soldier or a sailor (or a traveller), which would you choose? It's a tough call. Doctors believe most of mefloquine's psychological effects appear in the first three weeks of dosage, after which the mind seems to acclimate. So given enough notice of a deployment, it is possible to start mefloquine use before leaving home, and switch to an alternative if side effects start to appear. That's one solution. The Canadian Navy's approach since at least the early 1990s, of prescribing doxycycline as an alternative in case of the appearance of side effects or for people working particularly high stress jobs (like pilots), also seems to be sound. Chloroquine is no longer much use, but it's possible as physicians' confidence in the safety and efficacy of Malarone increases, it or some other drug still in the pipeline could soon be prescribed instead of mefloquine as the drug of choice for long overseas tours, which could solve the problem (assuming it doesn't have any amusing side effects of its own we don't know about yet).

Given the alternatives, I can't fault the American or Canadian militaries for relying heavily on mefloquine in previous years. Hopefully medical science will continue to advance to the point where there's better choices available.