Travel Advice: Malaria & Mefloquine (May-2025)
Dr Paul Pottinger ("Germ") & Dr Chris Sanford ("Worm") look at the pros and cons of Malaria and Mefloquine in May 2025
Via the Germ & Worm Podcast. Germ & Worm: 50: MAY-laria 2025! Podcast overview. A link and some commentary:
Salaam!
Today, travel medicine specialists Drs. Paul Pottinger ("Germ") & Chris Sanford ("Worm") answer your travel health questions about Malaria:
What's up with the malaria life cycle?
Are there different kinds of malaria?
Can you ever be truly cured of malaria, or is it with you forever once you catch it?
Can I take a self-testing kit when I travel?
Is there a malaria vaccine?
Is mefloquine really neurotoxic?
Is it safe for me to just watch out for malaria instead of taking medication?
Worth a listen. Transcript of the mefloquine content:
Alright Paul, next question for you. This comes from Gary in Dublin, Ireland. When I first went to Africa, specifically Ethiopia from Europe, Ireland, I was told I couldn’t take the recommended anti-malarial pill because I’m allergic to penicillin and I was given Lariam instead.
Very quickly, I started having incredibly graphic dreams and in one, I was a scarecrow and pulled straw from my arms and had bloody scratches on veins the next morning. The Doc immediately pulled me from the drug, and I just stopped worrying about malaria because of my location and height, East Ethiopia. So, my question is, is there any truth that Lariam is dangerous or did I just have a weird dream and the Doc overreacted?
Yeah, thanks Gary. It’s a great story, that vision of the scarecrow and the self-excoriation, that sounds like a bit bowl of bad. So, thanks for sharing that.
A few points here. You were given mefloquine, that’s the medical term of Lariam, as you called it, because you’re allergic to penicillin. So that’s not a thing.
And this may just be a miscommunication of some kind. Of course, I wasn’t there but there should be no penicillin product in any of the anti-malarial prevention medications that we use. So that’s one thing.
Number two, mefloquine, good drug to prevent malaria. I like it, and indeed, I’ve taken in before. Yes, it absolutely does have this association with vivid dreams.
It’s a once-a-week dose, how it’s usually given. And on that day in particular, people tend to have vivid dreams. For some, the are super pleasant, even arousing.
For others, they are terrifying. Usually, they’re described as just creepy and vivid, the most vivid dreams that somebody has. I have some patients who look forward to it.
I have some patients, like you, who are terrified and even potentially harmed by it. It’s not rare to have those vivid dreams. What is rare is genuine harm to the patient, a true neuropsychiatric break, major psychiatric problems.
That’s a super uncommon thing to happen. Having said so, if you look at the package insert, the official guidance that comes to us from the Food and Drug Administration, it does lay this out. And in fact, there’s a caution to prescribers that if the person who they’re prescribing for has a history, a person history of major psychiatric problems, I don’t mean depression.
That’s a common issue. I’m thinking about thought disorders, including schizophrenia. This medication is discouraged to be used in that population
Even though the cause of new major psychiatric break is incredibly rare and indeed difficult to tease apart. So, did that doctor overreact by stopping your antimalarials? Hey, the highlands of Ethiopia, beautiful place.
In many of those areas, in much of the year, your risk is relatively low, but there is hell P-VIVAX, Plasmodium VIVAX malaria in Ethiopia. It’s one of the things it’s known for. Som most of my patients go into most parts of Ethiopia.
I do recommend a preventative medication, but it doesn’t have to be mefloquine. We have other medications that can work well, including Malarone, which is one that’s not perfect for P-VIVAX, but pretty good, and that’s one of the things that I often recommend. Doxycycline, another reliable way to go.
Chris, what’s your clinical or personal experience with mefloquine?
Well, I took it for years. I took it probably for 20 years, and I never had any side effects, but my social group suggested that I did, but my baseline behaviour was such that they weren’t apparent. I never had any side effects that I was aware of.
However, I almost never prescribe it now, because it does have this association with nightmares and anxiety and depression, and there’s so many contraindications. Certain heart conditions, you shouldn’t take it. Certain neurological conditions, you shouldn’t take it.
And so, I’m tending to give something like Malarone, a combination of two drugs, much more often. So, it does have the advantage if it’s the only medication in the US that’s recommended for all three trimesters of pregnancy, but outside of a few rare circumstances, I don’t tend to prescribe it very much anymore. So yeah, your side effects indeed could have been caused by the medication.
And if you go to Ethiopia again, maybe consider taking Malarone.
So, my comment. I wouldn’t recommend mefloquine to my worst enemy but seek qualified medical advice prior to travelling.
UPDATES
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REFERENCES
Pottinger, P & Sanford, C (27.05.2025) 50: MAY-laria 2025! Podcast overview [Site linked in blog] Via Apple Podcasts. Page accessed 2.06.2025
Pottinger, P & Sanford, C (27.05.2025) 50: MAY-laria 2025! [https://www.doctortravel.com/germ-worm/] Via Travel Doctor Chris. Page accessed 3.06.2025