new Lariam - Travel Tips

Introduction

Lariam is an extremely controversial drug. The reason is very simple: a lot of people have no side effects of it, while other people will vehemently oppose any use of this drug because they had side effects of it.On this page, I will try to give objective info on the drug based on personnal stories, info from the Belgian tropical institute and I will also refer to some articles (both pro and con's) from the medical literature (with links to the abstracts of these articles).

Stories about Lariam

When you hear stories from fellow travellers, always be careful about the reliability of these stories. Here are 2 exemples of stories who look reliable, but in fact if you look a bit closer into it, you see that it's a misinterpretation of facts by people who are not medically trained. A friend of mine went to Senegal for 2 months and took Lariam as malaria prophylaxis. He has no problems with it, but after 2 weeks he gets fever and starts vomiting. After 3 days, things don't get better, and he goes to see a local doctor. This doctor doesn't do any tests, but says: "you surely have malaria, start taking Quinine and Doxycycline". After a couple of days, things get better, and now my friend is still telling everyone "he had malaria while on prophylaxis with Lariam", while in fact he probably just had a simple gastro-enteritis. The local doctor said he had malaria, because indeed most of his local patients, who don't take prophylaxis and have no problems with local food hygiene will indeed have malaria.The second story I read on the LP-site. A traveller said he had been using Lariam for 3 years without problems. The fourth year, he had a paralysis of his right face after 2 weeks. He went to his GP, and he said it was caused by Lariam. So he stopped Lariam and the paralysis went away after 2 weeks. This looks a reliable story, but in fact the GP was wrong, and the guy just had a "Bell's palsy", this is a viral infection of the facial nerve which resolves on its own. So Lariam had nothing to do with it.

Info provided by the Belgian tropical institute

Indications to take Lariam
Lariam will only be given for trips to WHO zone C countries. It is a very effective drug with an efficacy of 95 to 99%, this is the highest score for any preventive drug at the moment (1998). Even then you can get malaria while taking Lariam, although this is rare and maily confined to areas in Indochina (border area between Thailand-Myanmar-Cambodia). Resistance is up to 50% there. In certain areas of Western Africa, resistance is up to 10%.Lariam should be replaced by Nivaquine-Paludrine in the following conditions: Very long trips (> 11 weeks). However, there's a consensus that it can be safely used for a longer period if there's a good indication to do so and if the patient tolerates it well.In case of severe side effects of Lariam.If there's a safety risk like pilots, truck drivers, divers, because dizziness can have serious consequences in these people. For mountaineers, "the risk is not higher, but symptoms of altitude sickness can be confused with side effects of Lariam".Pregnant women and children less then 5 kg. Breastfeeding women can take Lariam. NOTE: Since 1994 the WHO says pregnant women in the second or third trimester can take Lariam if there's a good indication to do so.
Dose
The recommended profylactic dosage is 1 tablet of 250 mg once a week starting 1 week before you leave (for people who have taken it before and had no side effects) and continuing untill 4 weeks after you've left the area.It is advised not to take it longer then 16 weeks, but this can be extended in selected cases.
Contra-indications
Lariam should not be prescribed to patients with a personnal or a strong family history of psychiatric disturbances. Also in patient taking anti-anxiolytic drugs, Lariam should be avoided. In patients with a history of epileptic seizures, one should exert caution, as well as in patients with complaints of dizziness or equilibrium disturbances.Lariam should be avoided in patients using beta-blockers for cardiac rythm disturbances (if used for hypertension there's no contra-indication). The same goes for digoxin, quinidine and calcium blockers.Women of child bearing age should use a contraceptive method, although untill now there have been no reports of side effects on the foetus.
Side effects
80 % of people have no problems whatsoever.20 % have minor problems like slight stomach problems.5 % of patients has to stop taking the drug due to side effects like dizziness, heartbeats, sleeping problems, nightmares etc... Some of these symptoms may disappear when taking the drug before going asleep. These symptoms can be exacerbated by alcohol and fatigue. These symptoms have also been described with chloroquine/proguanil, but to a lesser extent.1/15.000 patients will develop serious side effects like severe depression, epileptic seizures or psychosis. A fatal outcome has never been described, (personnal note: there have been reports in the popular press of people having committed suicide after taking Lariam).
What to do if you've never taken Lariam
Start taking Lariam 3 weeks before you leave. If you get side effects, chances are 75 % you will get them the first 3 weeks, so you can seek advice at home.Otherwise take Lariam 250 mg/week starting a week before you leave and stopping 3 weeks after your return. Do not get pregnant till 3 months after stopping since Lariam can stay in your blood a long time ("half life" of the drug is 14 days in some people).
This part of the site is not finished yet
A personnal selection of articles in the medical literature
What randomised trials have been done with Lariam?
An article in the BMJ 1997 gave a review of 37 studies with Lariam. They rejected 27 because of bad design, so they kept 10. These are the withdrawal rates of these 10 trials:
width="29%">Lariam

Chloro/Prog.

Author	Patients	Comparison arms	Number participants	Withdrawal of the drug
Arthur	Soldiers	Lariam Doxy	134 119
Boudreau	Marines	Lariam load Lariam 1/week Chloro/Prog.	46 157 156	4,9% 3,2% 4,9%
Croft	Soldiers	317 307	1,8% 0,6%
Croft	Soldiers	Lariam Chloro/Prog.	275 268	2,1% 2,9%
Davis	Volunteer	Lariam Placebo	46 49
Kollaritsch	Volunteer	Lariam Chloro	60 60
McPherson	Volunteer	Lariam load Placebo	251 238	2,3% 0%
Ohrt	Soldiers	Lariam load Doxy Placebo	68 67 69	10% NK 5,7%
Schlagenhauf	Pilots	Lariam load Placebo	23 23	4,3% 0%
Vuurman	Volunteer	Lariam load Placebo	20 20	10% 0%

Conclusion of this review:

"The Ohrt study showed that Lariam is effective as profylaxis. However, withdrawal rates are higher in the Lariam group then in other groups, and this might impair effectiveness in general travellers".

Comparison of adverse events associated with use of mefloquine and combination of chloroquine and proguanil as antimalarial prophylaxis: postal and telephone survey of travellers

This study retrospectively questioned more then 2000 travellers after their return on side effects of either Lariam, either Chloroquine/Proguanil.

Side effects in both groups was 40%. However, there were more neuropsychiatric events in the Lariam arm (27% vs. 16%). These numbers are quite high, possibly due to the fact that people were questioned systematically. They will thus report events which they might otherwise forget. This goes for both groups of course. On top of that, 2 people in the Lariam group had to be admitted to the hospital.

This study in the BMJ has gotten a lot of attention in the media, because it said that severe side effects of Lariam were more common then previously reported, namely 1/607 instead of 1/15.000.

Malaria Chemoprophylaxis in German Tourists: A Prospective Study on Compliance and Adverse Reactions

This is a study (1996) in which 6504 German tourists were phoned 4 weeks after their return and were questionned about side effects. There were 3 groups: Lariam, Chloroquine + Proguanil and Chloroquine alone.

Withdrawal rates were 5,5% in Lariam, 14.1% in Chloroquine and 20,2 % in the CP group. Side effects occured in 20,6% in the 3 groups. People on Lariam reported neuropsychiatric side effects more often (6,5% vs. 3,9 %).

This is a retrospective study in a small journal.