Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers

Drug, generic (trade) name

Indication

Adult dosage

Pediatric dosage

Advantage

Disadvantage

Adverse effects

ATOVAQUONE / PROGUANIL (ATQ/PG) (Malarone®)

Prevention and
treatment of
P. falciparum

Adult tablet:
250 mg atovaquone plus 100 mg proguanil
Prevention:
1 tablet daily
Treatment:
1000 mg atovaquone
AND
400 mg proguanil (4 tab- lets) once daily x 3 days

Adult tablets
Prevention:
11-20 kg: ¼ tablet daily
21-30 kg: ½ tablet daily
31-40 kg: ¾ tablet daily
> 40 kg: 1 tablet daily
Treatment:
20 mg/kg atovaquone
AND
8mg/kg proguanil once
daily x 3 days
11-20 kg: 1 tablet daily
21-30 kg: 2 tablets daily
31-40 kg: 3 tablets daily
> 41 kg: 4 tablets daily

Causal prophylaxis - only have to continue for 7 days after exposure

Daily dosing for prophylaxis

Frequent:
Nausea, vomiting,
abdominal pain, diarrhea,
increased transaminases
Rare:
Seizures, rash, mouth
ulcers

CHLOROQUINE
(Aralen®)
Tablet: 150 mg
base

Prevention and treatment
in chloroquine-sensitive
P. falciparum
areas
Treatment of P. vivax,
P. ovale, P. malariae

Prevention:
300 mg base once weekly
Treatment:
1.5 g base over 3 days

Prevention:
5mg/kg base weekly;
maximum 300 mg
Treatment:
25 mg base/kg total over
3 days

Long-term safety data for
prophylaxis

Most areas now report
chloroquine resistance

Frequent:
Pruritis in black-skinned
individuals, nausea,
headache
Occasional:
Skin eruptions, reversible
corneal opacity
Rare:
Nail andmucousmembrane
discoloration,
partial alopecia, photophobia,
nerve deafness,
myopathy, retinopathy
with daily use, blood
dyscrasias, psychosis and
seizures

CLINDAMYCIN
(Dalacin C®)

Alternative treatment
for P. falciparum with a
second drug if standard
therapy contraindicated

Prevention:
no indication
Treatment oral:
300 mg base every 6 hr
for 5 days
Treatment IV:
10 mg/kg (loading dose)
intravenously, followed
by 5mg/kg every 8 hours
until blood is cleared of
asexual parasites or oral
therapy is tolerated.
NOTE: Should only use if
patient is unable to take
doxycycline or ATQ/PG

Prevention:
no indication
Treatment oral:
5mg/kg three times per day
for 5 days
Treatment IV:
10 mg/kg (loading dose)
intravenously, followed by 5
mg/kg every 8 hours until
blood is cleared of asexual
parasites or oral therapy is
tolerated. NOTE: Should only
use if patient is unable to
take doxycycline or ATVPG

Safe in pregnancy and
young children

Lower efficacy than
atovaquone/proguanil
alone or combination of
doxycycline plus quinine

Frequent:
Diarrhea, rash
Occasional:
Pseudomembranous
colitis
Rare:
Hepatotoxicity, blood
dyscrasias

DOXYCYCLINE
(Vibra-TabsTM)

Prevention and treatment
of chloroquine-resistant
P. falciparum

Prevention:
100 mg once daily
Treatment:
100 mg twice daily for 7
days

Prevention:
1.5mg base/kg once daily
(max 100 mg)
< 25 kg or < 8 yr: contraindicated
25-35 kg or 8-10 yr: 50mg
36-50 kg or 11-13 yr: 75mg
> 50 kg or > 14 yr: 100 mg
Treatment:
1.5mg base/kg twice daily
(max. 200 mg daily)
< 25 kg or < 8 yr: contraindicated
25-35 kg or 8-10 yr: 50mg
twice daily
36-50 kg or 11-13 yr: 75mg
twice daily
> 51 kg or > 14 yr: 100 mg
twice daily

Protection against
leptospirosis

Daily dosing required for
chemoprophylaxis

Frequent:
Gastrointestinal upset,
vaginal candidiasis,
photosensitivity
Occasional:
Azotemia in renal
diseases
Rare:
Allergic reactions, blood
dyscrasias, esophageal
ulceration

MEFLOQUINE
(Lariam®)

Prevention of
P. falciparum

Prevention:
250 mg base once weekly
Treatment:
not routinely recommended,
see text

Prevention:
5mg/kg weekly
< 5 kg: no data
5-9 kg:ctablet
10-19 kg: ¼ tablet 20-29
kg: ½ tablet
30-45 kg: ¾ tablet
> 46 kg: 1 tablet
Treatment:
not routinely recommended,
see text

Weekly dosing
Long-term safety data

There have been occasional
publicized cases of
severe intolerance to
mefloquine, which may
result in increased concern.
Ifmefloquine is the
best choice but concern is expressed, consider either
a loading dose or start 3
weeks before departure to test for tolerability.

Frequent:
Dizziness, headache, sleep
disorders, nightmares,
nausea, vomiting,
diarrhea
Occasional:
Sensory and motor
neuropathies, seizures,
abnormal coordination,
confusion, hallucinations,
forgetfulness, emotional
problems including anxiety,
aggression, agitation,
depression,mood
changes, panic attacks,
psychotic or paranoid
reactions, restlessness
Rare:
Suicidal ideation and suicide
(relation to drug
administration not
established)

PRIMAQUINE

Prevention of
chloroquine-resistant
P. falciparum
Terminal prophylaxis
P. vivax and P. ovale
Radical cure for P.vivax and
P. ovale infections

Prevention:
Primary prophylaxis 30
mg base daily, see text
Terminal prophylaxis or
radical cure:
30 mg base/day for 14
days

Prevention:
Primary prophylaxis 0.5
mg base/kg daily, see text
Terminal prophylaxis or
radical cure:
0.5mg base/kg daily for
14 days

Causal prophylaxis – only
have to continue for 7
days after exposure

Daily dosing
Require G6PD* testing,
see text

Occasional:
GI upset, hemolysis in
G6PD deficiency,
methemoglobinemia

QUINIDINE
GLUCONATE/
SULFATE

Prevention:
no indication
Treatment:
see Table 7

Prevention:
no indication
Treatment:
see Table 7.
28 mg base/kg daily,
divided q 8 hourly.**

Parenteral therapy
requires cardiac
monitoring

Frequent:
Vomiting, cramps, cinchonism
(tinnitus, nausea,
headache, blurred vision)
Occasional:
Widening of QRS complex,
cardiac disturbance, fever,
delirium, rashes
Rare:
Acute hemolytic anemia

QUININE DIHYDROCHLORIDE

Prevention:
no indication
Treatment:
See Table 7

Frequent:
Cinchonism (tinnitus, nausea,
headache, blurred
vision), hypoglycemia
Occasional:
Cardiac conduction disturbances,
hypersensitivity
Rare:
Hemolysis

QUININE SULPHATE
(Novoquinine®)

Prevention:
no indication
Treatment oral:
500 mg base three times
daily for 3-7 days (7 days for
S.E. Asia)
IV: see Table 7

Prevention:
no indication
Treatment oral:
7.5mg base/kg (max 500
mg base) three times daily
for 3-7 days (7 days for S.E.
Asia)
IV: see Table 7

Similar to above

*Glucose-6-phosphate dehydrogenase
**Suggested mixing instructions: to make 120 mL solution of concentration 8.3 mg base/mL combine 60 mL Orasweet and 60mL Oraplus with 6 x 200 mg tablets of crushed
quinidine sulfate.

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Table 8. Drugs for the treatment and prevention of malaria