HEALTH & SCIENCE

Anti-malaria drugs trigger care challenges

A murder investigation spotlights concern about Lariam's possible dark side.

By Victoria Stagg Elliott, AMNews staff. Sept. 23/30, 2002. Additional information

A drug prescribed to travelers to prevent and treat malaria has been mentioned by military officials as a possible factor in the separate murders of four Army wives over a six-week period at Fort Bragg, N.C., earlier this year.

Those events, coupled with manufacturer Roche Laboratories adding suicide risk to a list of rare but possible adverse reactions for Lariam (mefloquine hydrochloride), has increased the pressure on doctors to more selectively prescribe the anti-malaria drug.

A company spokesman confirmed the label changes but added that there is no proven link between the drug and violent behavior. "We can't comment on the Fort Bragg situation as we understand that there is an ongoing investigation of these events by the U.S. Army," said Terence Hurley. "It is important to note, however, that there is no reliable scientific evidence that Lariam is associated with violent acts or criminal conduct. Lariam is an important and valuable drug that's effective in fighting a life-threatening disease."

Patients with a history of mental illness are still considered at higher risk for adverse reactions, according to package labeling.

"The risk is relatively small, and when you prescribe selectively, the adverse events are not as much of a problem," said Bradley A. Connor, MD, medical director of the New York Center for Travel and Tropical Medicine. "But you don't want to leave someone unprotected. Malaria is a very serious infection, and whatever you can do to prevent it, you want to."

Lariam is the preferred choice because of cost, dosing and resistance considerations. And, though online travel journals are filled with tales of wild "Lariam dreams," these are more entertaining than debilitating, and most travelers do not experience adverse events.

Lariam is just one of many factors being investigated in the Fort Bragg murders, and there is speculation that the hunt for a possible link may be an effort to develop an insanity defense.

"The chances of this really causing you to go kill somebody, I think, are remote," said Brian S. Joseph, MD, a forensic psychiatrist in Buffalo, N.Y.

But for some patients, particularly those with a history of depression, the risks may be too high, and physicians are expected to offer other options. But even those who specialize in travel medicine concede that determining who is most at risk is not always an easy call. Where is the line between mild, moderate and severe depression? And when does the risk of malaria outweigh the risk of the drug?

"The problem is there so many people taking Prozac and Zoloft ... but not for a real, definite indication of psychiatric illness," said Martin Wolfe, MD, director of Traveler's Medical Service in Washington, D.C. "We're sometimes hesitant with those people if we can't get a good history. A definite contraindication is a history of psychiatric illness, but that's a broad term."

And sometimes the risk does not need to be taken. Travel medicine physicians speak anecdotally of patients given anti-malarials because they are going to a country where the illness exists, even though they are not going to areas where it is endemic.

"If you're going to Vietnam, but you're only going to Ho Chi Minh City or Hanoi, you're not at risk," said Dr. Connor. "If you're going to the countryside, you might be. You have to determine if [a patient] is really at risk."

Also, with four drugs now available to prevent malaria, the choices are harder, and the right one is not always made. Sometimes the wrong choice is deadly.

According to the Centers for Disease Control and Prevention, most people who developed malaria in the United States had traveled to a malarial region without taking any pharmacological precautions. More than 10%, however, had taken an anti-malarial, but it was not the right one for that particular area. The CDC has also recorded seven deaths over the past 10 years because the malaria was resistant to the prophylaxis prescribed.

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1973: 222
1983: 803
1993: 1,275
2000: 1,402

Source: Centers for Disease Control and Prevention

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Article, "Malaria Surveillance -- United States, 2000," Morbidity and Mortality Weekly Report, July 12 (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a2.htm)

Article on travel medicine for the primary care physician, from the Cleveland Clinic (http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/travel/travel.htm)

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Copyright 2002 American Medical Association. All rights reserved.