Key to recommended regimens for prophylaxis against malaria
Codes for regimens Details of regimens for prophylaxis against malaria
1 Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents
4 Atovaquone with proguanil hydrochloride or doxycycline or mefloquine
Country Comments on risk of malaria and regional or seasonal variation Codes for regimens
Afghanistan Low risk below 2000 m from May–November 1
Very low risk below 2000 m from December–April 1
Algeria Very low risk in remote focus in Illizi department only 1
Argentina Very low risk in low altitude areas of Salta provinces bordering Bolivia and in Chaco,
Corrientes, and Misiones provinces close to border with Paraguay and Brazil
No risk in Iguaçu Falls and areas other than those above -
Bangladesh High risk in Chittagong Hill Tract districts (but not Chittagong city) 4
Very low risk in Chittagong city and other areas, except Chittagong Hill Tract
Belize Low risk in rural areas 1
No risk in Belize district (including Belize city and islands) -
Bhutan Low risk in southern belt districts, along border with India: Chukha, Geyleg-phug,
Samchi, Samdrup Jonkhar, and Shemgang
No risk in areas other than those above -
Bolivia Low risk in Amazon basin 1
Low risk in rural areas below 2500 m (other than above) 1
Botswana High risk from November–June in northern half, including Okavango Delta area 4
Low risk from July–October in northern half 1
Very low risk in southern half 1
Brazil Low risk in Amazon basin, including city of Manaus 1
Very low risk in areas other than those above 1
Brunei Darussalam Very low risk 1
Cambodia Low risk. Mefloquine resistance widespread in western provinces bordering
Very low risk in Angkor Wat and Lake Tonle Sap, including Siem Reap 1
pregnant women, infants and young children, the elderly, and asplenic individuals)
should consider taking antimalarials, seek advice from a travel health advisor. Very
low risk on island of Santiago (Sao Tiago) and Boa Vista
Central African Republic High risk 4
Country Comments on risk of malaria and regional or seasonal variation Codes for regimens
China Low risk in Yunnan and Hainan provinces 1
Very low risk in southern and some central provinces, including Anhui, Ghuizhou,
Hena, Hubei, and Jiangsu below 1500 m
Very low risk in areas other than those above and below 1
Colombia Low risk in rural areas below 1600 m 1
Very low risk above 1600 m and in Cartagena 1
Costa Rica Low risk in Limon province, but not city of Limon (Puerto Limon) 1
Very low risk in areas other than those above 1
Cote d’Ivoire (Ivory Coast) High risk 4
No risk in cities of Santiago and Santo Domingo -
East Timor (Timor-Leste) Risk present 4
Ecuador Low risk in areas below 1500 m including coastal provinces and Amazon basin 1
No risk in Galapagos islands or city of Guayaquil -
El Salvador Low risk in rural areas of Santa Ana, Ahuachapán, and La Unión provinces in
western part of country; very low risk in other areas
Eritrea High risk below 2200 m 4
No risk in Asmara or in areas above 2200 m -
Ethiopia High risk below 2000 m 4
No risk in Addis Ababa or in areas above 2000 m -
French Guiana Risk present (particularly in border areas) except city of Cayenne or Devil’s Island
Low risk in city of Cayenne or Devil’s Island (Ile du Diable) 1
Georgia Very low risk in rural south east from June–October 1
Guatemala Low risk below 1500 m 1
No risk in Guatemala City, Antigua, or Lake Atitlan and above 1500 m -
Guyana Risk present in all interior regions 4
Very low risk in Georgetown and coastal region 1
Honduras Low risk below 1000 m and in Roatán and other Bay Islands 1
No risk in San Pedro Sula or Tegucigalpa and areas above 1000 m -
India Risk present in states of Assam and Orissa, districts of East Godavari, Srikakulam,
Vishakhapatnam, and Vizianagaram in the state of Andhra Pradesh, and districts of
Balaghat, Dindori, Mandla, and Seoni in the state of Madhya Pradesh
Low risk in areas other than those above or below (including Goa, Andaman and
Exceptional circumstances in low risk areas (dependent on individual risk
No risk in Lakshadweep islands -
Indonesia High risk in Irian Jaya (Papua) 4
Low risk in Bali, Lombok and islands of Java and Sumatra 1
610 Protozoal infection BNF 78
Key to recommended regimens for prophylaxis against malaria
Codes for regimens Details of regimens for prophylaxis against malaria
1 Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents
4 Atovaquone with proguanil hydrochloride or doxycycline or mefloquine
Country Comments on risk of malaria and regional or seasonal variation Codes for regimens
Iran Low risk from March–November in rural south eastern provinces and in north, along
Azerbaijan border in Ardabil, and near Turkmenistan border in North Khorasan
Very low risk in areas other than those above 1
Iraq Very low risk from May–November in rural northern area below 1500 m 1
No risk in areas other than those above -
Kenya High risk (except city of Nairobi) 4
Very low risk in the highlands above 2500 m and in city of Nairobi 1
Very low risk in city of Vientiane 1
Malaysia Low risk in mainland Malaysia 1
Malaysia (Borneo) Low risk in inland areas of Sabah and in inland, forested areas of Sarawak 1
Very low risk in areas other than those above, including coastal areas of Sabah and
Mauritania High risk all year in southern provinces, and from July–October in the northern
Low risk from November–June in the northern provinces 1
Namibia High risk all year in regions of Caprivi Strip, Kavango, and Kunene river, and from
November–June in northern third of country
Very low risk in areas other than those above; low risk from July–October in
Nepal Low risk below 1500 m, including the Terai district 1
No risk in city of Kathmandu and on typical Himalayan treks -
Nicaragua Low risk (except Managua) 1
North Korea Very low risk in some southern areas 1
Pakistan Low risk below 2000 m 1
Panama Low risk east of Canal Zone 1
Very low risk west of Canal Zone 1
No risk in Panama City or Canal Zone itself -
Papua New Guinea High risk below 1800 m 4
Country Comments on risk of malaria and regional or seasonal variation Codes for regimens
Peru Low risk in Amazon basin along border with Brazil, particularly in Loreto province
and in rural areas below 2000 m including the Amazon basin bordering Bolivia
No risk in city of Lima and coastal region south of Chiclayo -
Philippines Low risk in rural areas below 600 m and on islands of Luzon, Mindanao, Mindoro,
No risk in cities or on islands of Boracay, Bohol, Catanduanes, Cebu, or Leyte -
São Tomé and Principe High risk 4
Saudi Arabia Low risk in south-western provinces along border with Yemen, including below
No risk in cities of Jeddah, Makkah (Mecca), Medina, Riyadh, or Ta’if, or above
South Africa Risk from September–May in low altitude areas of Mpumalanga and Limpopo,
particularly those bordering Mozambique, Swaziland (Estwatini), and Zimbabwe
(including Kruger National Park)
Low risk in north-east KwaZulu-Natal and in designated areas of Mpumalanga and
Very low risk in North West Province (adjacent to Molopo river) and Northern Cape
Province (adjacent to Orange river)
South Korea Very low risk in northern areas, in Gangwon-do and Gyeonggi-do provinces, and
Incheon city (towards Demilitarized Zone)
Sri Lanka Low risk north of Vavuniya 1
Very low risk in areas other than those above and below 1
Sudan High risk in central and southern areas; risk also present in rest of country (except
Suriname Risk present on the French Guiana border 4
Low risk in areas other than above and below 1
No risk in city of Paramaribo -
Swaziland Risk in northern and eastern regions bordering Mozambique and South Africa,
including all of Lubombo district and Big Bend, Mhlume, Simunye, and Tshaneni
Very low risk in the areas other than those above 1
Syria Very low risk in small, remote foci of El Hasakah 1
Tanzania High risk below 1800 m; risk also in Zanzibar 4
Thailand Mefloquine resistance present. Low risk in rural forested borders with Cambodia,
Very low risk in areas other than those above, including Kanchanaburi (Kwai Bridge) 1
No risk in cities of Bangkok, Chiang Mai, Chiang Rai, Koh Phangan, Koh Samui, and
Uzbekistan Very low risk in extreme south-east 1
612 Protozoal infection BNF 78
In view of the continuing emergence of resistant strains and
of the different regimens required for different areas expert
advice should be sought on the best treatment course for an
individual traveller. A drug used for chemoprophylaxis
should not be considered for standby treatment for the same
Malaria prophylaxis, specific recommendations
Travellers planning journeys across continents can travel
into areas that have different malaria prophylaxis
recommendations. The choice of prophylaxis medication
must reflect overall risk to ensure protection in all areas; it
may be possible to change from one regimen to another.
Those travelling to remote or little-visited areas may require
expert advice. For further information see Recommended
regimens for prophylaxis against malaria, and Public Health
England Guidelines for malaria prevention in travellers from
Settled immigrants (or long-term visitors) to the UK may be
unaware that any immunity they may have acquired while
living in malarious areas is lost rapidly after migration to
the UK, or that any non-malarious areas where they lived
previously may now be malarious.
Advice for healthcare professionals
A number of specialist centres are able to provide advice on
PHE (Public Health England) Malaria Reference Laboratory
(020) 7637 0248 (fax) (prophylaxis only) www.malariareference.co.uk
National Travel Health Network and Centre 0845 602 6712
Monday and Friday: 9–11 a.m. and 1–2 p.m, Tuesday to
Thursday: 9–11 a.m. and 1–3:30 p.m. travelhealthpro.org.uk/
Travel Medicine Team, Health Protection Scotland
(registered users of Travax only) www.travax.nhs.uk (for
registered users of the NHS Travax website only) (0141) 300
London 0845 155 5000 (treatment)
Hospital for Tropical Diseases Travel Healthline (020) 7950
WHO advice on international travel and health www.who.int/
National Travel Health Network and Centre (NaTHNaC)
Recommendations on the treatment of malaria reflect
guidelines agreed by UK malaria specialists.
If the infective species is not known, or if the infection is
mixed, initial treatment should be as for falciparum malaria
with quinine p. 619, Malarone ® (atovaquone with proguanil
hydrochloride p. 615), or Riamet ® (artemether with
lumefantrine p. 614). Falciparum malaria can progress
rapidly in unprotected individuals and antimalarial
treatment should be considered in those with features of
severe malaria and possible exposure, even if the initial
blood tests for the organism are negative.
Falciparum malaria (treatment)
Falciparum malaria (malignant malaria) is caused by
Plasmodium falciparum. In most parts of the world P.
falciparum is now resistant to chloroquine p. 616 which
should not therefore be given for treatment.
Key to recommended regimens for prophylaxis against malaria
Codes for regimens Details of regimens for prophylaxis against malaria
1 Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents
4 Atovaquone with proguanil hydrochloride or doxycycline or mefloquine
Country Comments on risk of malaria and regional or seasonal variation Codes for regimens
Venezuela Risk in all areas south of, and including, the Orinoco river and Angel Falls, rural
areas of Apure, Monagas, Sucre, and Zulia states
No risk in city of Caracas or on Margarita Island -
Vietnam Low risk in rural areas, and in southern provinces of Tay Ninh, Lam Dong, Dac Lac,
No risk in large cities (including Ho Chi Minh City (Saigon) and Hanoi), the Red River
delta, coastal areas north of Nha Trang and Phu Quoc Island
Very low risk on Socrota Island; no risk above 2000 m, including Sana’a city 1
Zimbabwe High risk all year in Zambezi valley, and from November–June in areas below
Low risk from July–October in areas below 1200 m; very low risk all year in Harare
Quinine, Malarone® (atovaquone with proguanil
hydrochloride), or Riamet® (artemether with lumefantrine)
can be given by mouth if the patient can swallow and retain
tablets and there are no serious manifestations (e.g.
impaired consciousness); quinine should be given by
intravenous infusion if the patient is seriously ill or unable to
take tablets. Mefloquine p. 617 is now rarely used for
treatment because of concerns about resistance.
Oral quinine is given by mouth for 5–7 days, together with
or followed by either doxycycline p. 564 for 7 days or
clindamycin p. 535 for 7 days [unlicensed].
If the parasite is likely to be sensitive, pyrimethamine with
sulfadoxine as a single dose [unlicensed] may be given
(instead of either clindamycin or doxycycline) together with,
or after, a course of quinine.
Alternatively, Malarone ®, or Riamet ® may be given
instead of quinine. It is not necessary to give clindamycin,
doxycycline, or pyrimethamine with sulfadoxine after
Malarone ® or Riamet ® treatment.
If the patient is seriously ill or unable to take tablets, or if
more than 2% of red blood cell are parasitized, quinine
should be given by intravenous infusion [unlicensed] (until
patient can swallow tablets to complete the 7-day course
together with or followed by either doxycycline or
Specialist advice should be sought in difficult cases (e.g.
very high parasite count, deterioration on optimal doses of
quinine, infection acquired in quinine-resistant areas of
south east Asia) because intravenous artesunate may be
available for ‘named-patient’ use.
Falciparum malaria is particularly dangerous in pregnancy,
especially in the last trimester. The adult treatment doses or
oral and intravenous quinine (including the loading dose)
can safely be given to pregnant women. Clindamycin should
be given after quinine [unlicensed indication]. Doxycycline
should be avoided in pregnancy (affects teeth and skeletal
development); pyrimethamine with sulfadoxine, Malarone ®,
and Riamet ® are also best avoided until more information is
available. Specialist advice should be sought in difficult cases
(e.g. very high parasite count, deterioration on optimal doses
of quinine, infection acquired in quinine-resistant areas of
south east Asia) because intravenous artesunate may be
available for ‘named patient’ use.
Non-falciparum malaria (treatment)
Non-falciparum malaria is usually caused by Plasmodium
vivax and less commonly by P. ovale and P. malariae. P.
knowlesi is also present in the Asia-Pacific region.
been reported in the Indonesian archipelago, the Malay
Peninsula, including Myanmar, and eastward to Southern
For the treatment of chloroquine-resistant non-falciparum
malaria, Malarone ® [unlicensed indication], quinine, or
Riamet ® [unlicensed indication] can be used; as with
chloroquine, primaquine p. 618 should be given for radical
Chloroquine alone is adequate for P. malariae and P.
knowlesi infections but in the case of P. vivax and P. ovale, a
radical cure (to destroy parasites in the liver and thus prevent
relapses) is required. This is achieved with primaquine
[unlicensed] given after chloroquine, with the dose
dependent on the infecting organism. For a radical cure,
primaquine [unlicensed] is then given for 14 days, with the
dose also dependent on the infecting organism.
Parenteral If the patient is unable to take oral therapy,
quinine can be given by intravenous infusion [unlicensed],
changed to oral chloroquine as soon as the patient’s
The adult treatment doses of chloroquine can be given for
non-falciparum malaria. In the case of P. vivax or P. ovale,
however, the radical cure with primaquine should be
postponed until the pregnancy is over; instead chloroquine
should be continued, given weekly during the pregnancy.
ANTIPROTOZOALS › ANTIMALARIALS
Artemether with lumefantrine 28-May-2018
Treatment of acute uncomplicated falciparum malaria |
Treatment of chloroquine-resistant non-falciparum
▶ Adult (body-weight 35 kg and above): Initially 4 tablets,
followed by 4 tablets for 5 doses each given at 8, 24, 36,
48 and 60 hours (total 24 tablets over 60 hours)
l UNLICENSED USE Use in treatment of non-falciparum
malaria is an unlicensed indication.
l CONTRA-INDICATIONS Family history of congenital QT
bradycardia . history of congestive heart failure
accompanied by reduced left ventricular ejection fraction
l CAUTIONS Avoid in Acute porphyrias p. 1058 . electrolyte
l INTERACTIONS → Appendix 1: antimalarials
▶ Common or very common Abdominal pain . appetite
▶ Frequency not known Angioedema
l PREGNANCY Toxicity in animal studies with artemether.
Manufacturer advises use only if potential benefit
l BREAST FEEDING Manufacturer advises avoid
breastfeeding for at least 1 week after last dose. Present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available)—monitor
ECG and plasma potassium concentration.
l RENAL IMPAIRMENT Manufacturer advises caution in
Monitoring In severe renal impairment monitor ECG and
plasma potassium concentration.
l MONITORING REQUIREMENTS Monitor patients unable to
take food (greater risk of recrudescence).
l DIRECTIONS FOR ADMINISTRATION Tablets may be crushed
Driving and skilled tasks Dizziness may affect performance
of skilled tasks (e.g. driving).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 21
▶ Riamet (Novartis Pharmaceuticals UK Ltd)
Artemether 20 mg, Lumefantrine 120 mg Riamet tablets |
614 Protozoal infection BNF 78
(Piperaquine tetraphosphate with
Treatment of uncomplicated falciparum malaria
▶ Child 6 months–17 years (body-weight 7–12 kg): 0.5 tablet
once daily for 3 days, max. 2 courses in 12 months;
second course given at least 2 months after first course
▶ Child 6 months–17 years (body-weight 13–23 kg): 1 tablet
once daily for 3 days, max. 2 courses in 12 months;
second course given at least 2 months after first course
▶ Child 6 months–17 years (body-weight 24–35 kg): 2 tablets
once daily for 3 days, max. 2 courses in 12 months;
second course given at least 2 months after first course
▶ Child 6 months–17 years (body-weight 36–74 kg): 3 tablets
once daily for 3 days, max. 2 courses in 12 months;
second course given at least 2 months after first course
▶ Child 6 months–17 years (body-weight 75–99 kg): 4 tablets
once daily for 3 days, max. 2 courses in 12 months;
second course given at least 2 months after first course
▶ Adult (body-weight 36–74 kg): 3 tablets once daily for
3 days, max. 2 courses in 12 months; second course
given at least 2 months after first course
▶ Adult (body-weight 75–99 kg): 4 tablets once daily for
3 days, max. 2 courses in 12 months; second course
given at least 2 months after first course
disturbances .family history of sudden death . heart failure
with reduced left ventricular ejection fraction . history of
l INTERACTIONS → Appendix 1: antimalarials
children). leucopenia (in children). neutropenia (in
children). QT interval prolongation .thrombocytopenia
children). diarrhoea (very common in children). dizziness
(very common in children). lymphadenopathy (in
children). myalgia (in adults). nausea .rhinorrhoea (in
children). seizure . skin reactions (very common in
children). splenomegaly (in children). stomatitis (in
children).thrombocytosis (in children). vomiting (very
l PREGNANCY Teratogenic in animal studies—manufacturer
advises use only if other antimalarials cannot be used.
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
jaundice or in moderate to severe failure (no information
available)—monitor ECG and plasma potassium
Monitoring Manufacturer advises monitor ECG and
plasma-potassium concentration in moderate to severe
l RENAL IMPAIRMENT No information available in moderate
Monitoring Manufacturer advises monitor ECG and
plasma-potassium concentration in moderate to severe
▶ Consider obtaining ECG in all patients before third dose
and 4–6 hours after third dose. If QTC interval more than
500 milliseconds, discontinue treatment and monitor ECG
▶ Obtain ECG as soon as possible after starting treatment
then continue monitoring in those taking medicines that
increase plasma-piperaquine concentration, in children
who are vomiting, in females, or in the elderly.
l DIRECTIONS FOR ADMINISTRATION Tablets to be taken at
least 3 hours before and at least 3 hours after food. Tablets
may be crushed and mixed with water immediately before
l PATIENT AND CARER ADVICE Patients or carers should be
given advice on how to administer tablets containing
piperaquine phosphate with artenimol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Eurartesim (Logixx Pharma Solutions Ltd) A
Artenimol 40 mg, Piperaquine phosphate 320 mg Eurartesim
320mg/40mg tablets | 12 tablet P £40.00
Prophylaxis of falciparum malaria, particularly where
resistance to other antimalarial drugs suspected
▶ Adult (body-weight 40 kg and above): 1 tablet once daily,
to be started 1–2 days before entering endemic area
and continued for 1 week after leaving
Treatment of acute uncomplicated falciparum malaria |
Treatment of non-falciparum malaria
▶ Adult: 4 tablets once daily for 3 days
DOSE EQUIVALENCE AND CONVERSION
▶ Each tablet of Malarone ® contains 250 mg of
atovaquone and 100 mg of proguanil hydrochloride.
l UNLICENSED USE Not licensed for treatment of nonfalciparum malaria.
l CAUTIONS Diarrhoea or vomiting (reduced absorption of
atovaquone). efficacy not evaluated in cerebral or
complicated malaria (including hyperparasitaemia,
pulmonary oedema or renal failure)
l INTERACTIONS → Appendix 1: antimalarials
▶ Common or very common Abdominal pain . appetite
▶ Uncommon Alopecia . anxiety . blood disorder. hyponatraemia . oral disorders . palpitations
syndrome .tachycardia . vasculitis
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk. See also Pregnancy in Malaria,
l BREAST FEEDING Use only if no suitable alternative
l RENAL IMPAIRMENT Avoid for malaria prophylaxis (and if
possible for malaria treatment) if eGFR less than
l PATIENT AND CARER ADVICE Warn travellers about
importance of avoiding mosquito bites, importance of
taking prophylaxis regularly, and importance of
immediate visit to doctor if ill within 1 year and especially
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Drugs for malaria prophylaxis are not
prescribable in NHS primary care; health authorities may
investigate circumstances under which antimalarials are
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 21
▶ Malarone (GlaxoSmithKline UK Ltd)
Proguanil hydrochloride 100 mg, Atovaquone 250 mg Malarone
250mg/100mg tablets | 12 tablet P £25.21 DT = £25.21
Active rheumatoid arthritis (administered on expert
advice)| Systemic and discoid lupus erythematosus
(administered on expert advice)
▶ Adult: 155 mg daily; maximum 2.5 mg/kg per day
▶ INITIALLY BY MOUTH USING SYRUP
▶ Child 4–5 weeks (body-weight up to 4.5 kg): 25 mg once
weekly, started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 6 weeks–5 months (body-weight 4.5–7 kg): 50 mg
once weekly, started 1 week before entering endemic
area and continued for 4 weeks after leaving
▶ Child 6–11 months (body-weight 8–10 kg): 75 mg once
weekly, started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 1–2 years (body-weight 11–14 kg): 100 mg once
weekly, started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 3–4 years (body-weight 15–16.4 kg): 125 mg once
weekly, started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 5–7 years (body-weight 16.5–24 kg): 150 mg once
weekly, alternatively (by mouth using tablets) 155 mg
once weekly, started 1 week before entering endemic
area and continued for 4 weeks after leaving
▶ Child 8–13 years (body-weight 25–44 kg): 225 mg once
weekly, alternatively (by mouth using tablets) 232.5 mg
once weekly, started 1 week before entering endemic
area and continued for 4 weeks after leaving
▶ INITIALLY BY MOUTH USING TABLETS
▶ Child 14–17 years (body-weight 45 kg and above): 310 mg
once weekly, alternatively (by mouth using syrup)
300 mg once weekly, started 1 week before entering
endemic area and continued for 4 weeks after leaving
▶ Adult (body-weight 45 kg and above): 310 mg once
weekly, alternatively (by mouth using syrup) 300 mg
once weekly, started 1 week before entering endemic
area and continued for 4 weeks after leaving
Treatment of non-falciparum malaria
▶ Child: Initially 10 mg/kg (max. per dose 620 mg), then
5 mg/kg after 6–8 hours (max. per dose 310 mg), then
5 mg/kg daily (max. per dose 310 mg) for 2 days
▶ Adult: Initially 620 mg, then 310 mg after 6–8 hours,
then 310 mg daily for 2 days, approximate total
cumulative dose of 25 mg/kg of base
P. vivax or P. ovale infection during pregnancy while
DOSE EQUIVALENCE AND CONVERSION
▶ Doses expressed as chloroquine base.
▶ Each tablet contains 155 mg of chloroquine base
(equivalent to 250 mg of chloroquine phosphate).
Syrup contains 50 mg/5 mL of chloroquine base
(equivalent to 80 mg/5 mL of chloroquine phosphate).
DOSES AT EXTREMES OF BODY-WEIGHT
▶ With oral use in adults In active rheumatoid arthritis and
systemic and discoid lupus erythematosus, to avoid
excessive dosage in obese patients, the daily maximum
dose should be calculated on the basis of ideal body
l UNLICENSED USE Chloroquine doses for the treatment and
prophylaxis of malaria in BNF publications may differ from
Ocular toxicity is unlikely if the dose of chloroquine
phosphate does not exceed 4 mg/kg daily (equivalent to
chloroquine base approx. 2.5 mg/kg daily).
l CAUTIONS Acute porphyrias p. 1058 . diabetes (may lower
blood glucose). elderly .G6PD deficiency . long-term
therapy (regular ophthalmic examination recommended
by manufacturers). may aggravate myasthenia gravis . may
exacerbate psoriasis . neurological disorders, especially
epilepsy (may lower seizure threshold)—avoid for
prophylaxis of malaria if history of epilepsy . severe gastrointestinal disorders
▶ In adults A review group convened by the Royal College of
Ophthalmologists has updated guidelines on screening for
chloroquine and hydroxychloroquine retinopathy
(Hydroxychloroquine and Chloroquine Retinopathy:
Recommendations on Screening 2018). Chloroquine appears
to be more retinotoxic than hydroxychloroquine.
Screening recommendations for chloroquine:
. All patients planning to be on long-term treatment
should receive a baseline examination (including fundus
photography and spectral domain optical coherence
tomography) within 6-12 months of treatment
. Annual screening is recommended in all patients who
have taken chloroquine for greater than 1 year.
l INTERACTIONS → Appendix 1: antimalarials
▶ Rare or very rare Cardiomyopathy . hallucination . hepatitis
reactions .thrombocytopenia .tinnitus .tongue protrusion . vision disorders . vomiting
616 Protozoal infection BNF 78
SIDE-EFFECTS, FURTHER INFORMATION Side-effects which
occur at doses used in the prophylaxis or treatment of
malaria are generally not serious.
Overdose Chloroquine is very toxic in overdosage;
overdosage is extremely hazardous and difficult to treat.
Urgent advice from the National Poisons Information
Service is essential. Life-threatening features include
arrhythmias (which can have a very rapid onset) and
convulsions (which can be intractable).
l PREGNANCY Benefit of use in prophylaxis and treatment
in malaria outweighs risk. For rheumatoid disease, it is not
necessary to withdraw an antimalarial drug during
pregnancy if the disease is well controlled.
disease. Amount in milk probably too small to be harmful
l HEPATIC IMPAIRMENT Manufacturer advises caution,
l RENAL IMPAIRMENT Manufacturers advise caution.
Dose adjustments Only partially excreted by the kidneys
and reduction of the dose is not required for prophylaxis of
malaria except in severe impairment.
For rheumatoid arthritis and lupus erythematosus,
▶ In adults Manufacturers recommend regular
ophthalmological examination but the evidence of
practical value is unsatisfactory.
▶ In children Ophthalmic examination with long-term
l PATIENT AND CARER ADVICE Warn travellers going to
malarious areas about importance of avoiding mosquito
bites, importance of taking prophylaxis regularly, and
importance of immediate visit to doctor if ill within 1 year
and especially within 3 months of return.
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Drugs for malaria prophylaxis are not
prescribable in NHS primary care; health authorities may
investigate circumstances under which antimalarials are
l EXCEPTIONS TO LEGAL CATEGORY Can be sold to the public
provided it is licensed and labelled for the prophylaxis of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
CAUTIONARY AND ADVISORY LABELS 5
▶ Malarivon (Wallace Manufacturing Chemists Ltd)
Chloroquine phosphate 16 mg per 1 ml Malarivon 80mg/5ml syrup
CAUTIONARY AND ADVISORY LABELS 5
▶ Avloclor (Alliance Pharmaceuticals Ltd)
Chloroquine phosphate 250 mg Avloclor 250mg tablets | 20 tablet P £8.59 DT = £8.59
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, chloroquine p. 616, proguanil hydrochloride
▶ Adult: (consult product literature)
l INTERACTIONS → Appendix 1: antimalarials
l EXCEPTIONS TO LEGAL CATEGORY Can be sold to the public
provided it is licensed and labelled for the prophylaxis of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Paludrine/Avloclor (Alliance Pharmaceuticals Ltd)
Paludrine/Avloclor tablets anti-malarial travel pack | 112 tablet p
▶ Adult: (consult product literature)
▶ Child (body-weight 5–15 kg): 62.5 mg once weekly, dose
to be started 2–3 weeks before entering endemic area
and continued for 4 weeks after leaving
▶ Child (body-weight 16–24 kg): 125 mg once weekly, dose
to be started 2–3 weeks before entering endemic area
and continued for 4 weeks after leaving
▶ Child (body-weight 25–44 kg): 187.5 mg once weekly,
dose to be started 2–3 weeks before entering endemic
area and continued for 4 weeks after leaving
▶ Child (body-weight 45 kg and above): 250 mg once
weekly, dose to be started 2–3 weeks before entering
endemic area and continued for 4 weeks after leaving
▶ Adult (body-weight 45 kg and above): 250 mg once
weekly, dose to be started 2–3 weeks before entering
endemic area and continued for 4 weeks after leaving
l UNLICENSED USE Mefloquine doses in BNF Publications
may differ from those in product literature.
▶ In children Not licensed for use in children under 5 kg
body-weight and under 3 months.
l CONTRA-INDICATIONS Avoid for prophylaxis if history of
psychiatric disorders (including depression) or convulsions
. avoid for standby treatment if history of convulsions . history of blackwater fever
l CAUTIONS Cardiac conduction disorders . epilepsy (avoid
for prophylaxis). not recommended in infants under
3 months (5 kg)(in children).traumatic brain injury
▶ Neuropsychiatric reactions Mefloquine is associated with
potentially serious neuropsychiatric reactions. Abnormal
dreams, insomnia, anxiety, and depression occur
commonly. Psychosis, suicidal ideation, and suicide have
also been reported. Psychiatric symptoms such as
insomnia, nightmares, acute anxiety, depression,
restlessness, or confusion should be regarded as
potentially prodromal for a more serious event. Adverse
reactions may occur and persist up to several months after
discontinuation because mefloquine has a long half-life.
For a prescribing checklist, and further information on
side-effects, particularly neuropsychiatric side-effects,
which may be associated with the use of mefloquine for
malaria prophylaxis, see the Guide for Healthcare
Professionals provided by the manufacturer.
l INTERACTIONS → Appendix 1: antimalarials
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with hypersensitivity to quinine.
l CONCEPTION AND CONTRACEPTION Manufacturer advises
adequate contraception during prophylaxis and for
3 months after stopping (teratogenicity in animal studies).
l PREGNANCY Manufacturer advises avoid (particularly in
the first trimester) unless the potential benefit outweighs
the risk; however, studies of mefloquine in pregnancy
(including use in the first trimester) indicate that it can be
considered for travel to chloroquine-resistant areas.
l BREAST FEEDING Present in milk but risk to infant
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment—elimination may be prolonged.
l RENAL IMPAIRMENT Manufacturer advises caution.
l DIRECTIONS FOR ADMINISTRATION Tablet may be crushed
and mixed with food such as jam or honey just before
l PATIENT AND CARER ADVICE Manufacturer advises that
patients receiving mefloquine for malaria prophylaxis
should be informed to discontinue its use if
neuropsychiatric symptoms occur and seek immediate
medical advice so that mefloquine can be replaced with an
alternative antimalarial. Travellers should also be warned
about importance of avoiding mosquito bites,
importance of taking prophylaxis regularly, and
importance of immediate visit to doctor if ill within 1 year
and especially within 3 months of return.
A patient alert card should be provided.
Driving and skilled tasks Dizziness or a disturbed sense of
balance may affect performance of skilled tasks (e.g.
driving); effects may occur and persist up to several
months after stopping mefloquine.
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Drugs for malaria prophylaxis are not
prescribable in NHS primary care; health authorities may
investigate circumstances under which antimalarials are
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 10, 21, 27
▶ Lariam (Cheplapharm Arzneimittel GmbH)
Mefloquine (as Mefloquine hydrochloride) 250 mg Lariam 250mg
tablets | 8 tablet P £14.53 DT = £14.53
Adjunct in the treatment of non-falciparum malaria
▶ Adult: 30 mg daily for 14 days
Adjunct in the treatment of non-falciparum malaria
▶ Adult: 15 mg daily for 14 days
Adjunct in the treatment of non-falciparum malaria
caused by P.vivax infection in patients with mild G6PD
deficiency (administered on expert advice)| Adjunct in
the treatment of non-falciparum malaria caused by
P.ovale infection in patients with mild G6PD deficiency
(administered on expert advice)
▶ Adult: 45 mg once weekly for 8 weeks
Treatment of mild to moderate pneumocystis infection (in
▶ Adult: 30 mg daily, this combination is associated with
l UNLICENSED USE Not licensed.
l CAUTIONS G6PD deficiency . systemic diseases associated
with granulocytopenia (e.g. juvenile idiopathic arthritis,
rheumatoid arthritis, lupus erythematosus)
l INTERACTIONS → Appendix 1: antimalarials
▶ Common or very common Abdominal pain . appetite
▶ Uncommon Haemolytic anaemia (more common in G6PD
deficiency) . leucopenia . methaemoglobinaemia
l PREGNANCY Risk of neonatal haemolysis and
methaemoglobinaemia in third trimester.
l BREAST FEEDING No information available; theoretical
risk of haemolysis in G6PD-deficient infants.
l PRE-TREATMENT SCREENING Before starting primaquine,
blood should be tested for glucose-6-phosphate
dehydrogenase (G6PD) activity since the drug can cause
haemolysis in G6PD-deficient patients. Specialist advice
should be obtained in G6PD deficiency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
▶ Primaquine (Non-proprietary)
Primaquine (as Primaquine phosphate) 7.5 mg Primaquine 7.5mg
Primaquine (as Primaquine phosphate) 15 mg Primaquine 15mg
▶ Child 4–11 weeks (body-weight up to 6 kg): 25 mg once
daily, dose to be started 1 week before entering
endemic area and continued for 4 weeks after leaving
▶ Child 3–11 months (body-weight 6–9 kg): 50 mg once daily,
dose to be started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 1–3 years (body-weight 10–15 kg): 75 mg once daily,
dose to be started 1 week before entering endemic area
and continued for 4 weeks after leaving
▶ Child 4–7 years (body-weight 16–24 kg): 100 mg once
daily, dose to be started 1 week before entering
endemic area and continued for 4 weeks after leaving
▶ Child 8–12 years (body-weight 25–44 kg): 150 mg once
daily, dose to be started 1 week before entering
endemic area and continued for 4 weeks after leaving
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