Previous changes

July 2023 — minor update. Removed proguanil as this has been discontinued in the UK. 

August 2022 — reviewed. A literature search was conducted in June 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been some minor structural changes to this topic, but no changes to recommendations. 

July 2021 — minor update. Added information about potential cardiovascular risk of prescribing chloroquine with macrolide antibiotics. 

March 2021 — minor update. Suicidal behaviour and psychiatric disorders have been added to the adverse effects of chloroquine in line with updated manufacturer's SPC.

January 2018 — reviewed. A literature search was conducted in November 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

January 2017 — minor update. Recommended chemoprophylactic dose of mefloquine added as per changes to the manufacturer's Summary of Product Characteristics.

December 2016 — minor update. The contraindications and cautions, and adverse effects of chloroquine have been updated in line with changes to the manufacturer's Summary of Product Characteristics.

November 2013 — minor update. Text changed in prescribing information section for mefloquine in line with the updated Summary of Product Characteristics.

May 2013 — minor update. Typographical errors corrected.

March 2012 — revised. A literature search was conducted in October 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made. The topic has been restructured to improve clarity and navigation. 

October 2010 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

October 2009 — minor update. Advice that antacids and chloroquine should be taken 4 hours apart has been added to the Prescribing Information section. 

December 2008 — minor update. Black triangle removed from Malarone Paediatric^®.

March to July 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

November 2005 — minor technical update. 

April 2004 — reviewed, incorporating new Health Protection Agency (formerly the Public Health Laboratory Service) guidance on malaria prophylaxis. Validated in September 2004 and issued in November 2004.

November 2001 — reviewed, incorporating new Public Health Laboratory Service guidance on malaria prophylaxis. Validated in March 2002 and issued in April 2002.

October 1998 — written.

New evidence

Evidence-based guidelines

• UKHSA (2023) Malaria prevention guidelines for travellers from the UK. UK Health Security Agency. www.gov.uk [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses published since 1 August 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2022.

New policies

No new national policies or guidelines since 1 August 2022.

New safety alerts

No new safety alerts since 1 August 2022.

Changes in product availability

Proguanil has been discontinued in the UK from 23rd June 2023. This update was provided by the UK Health Security Agency. 

Basis for recommendation

These recommendations are based on the UK Health Security Agency (UKHSA) Guidelines for malaria prevention in travellers from the UK [UKHSA, 2024], the National Travel Health Network and Centre (NaTHNaC) factsheet Malaria [NaTHNaC, 2022], the Canadian Summary of recommendations for the prevention of malaria by the Committee to Advise on Tropical Medicine and Travel (CATMAT) [CATMAT, 2014], and the US Centers for Disease Control and Prevention (CDC) CDC Yellow Book 2018. Health information for international travel [CDC, 2020]. 

Assess the risk of malaria using the ACMP guidelines

• UK Health Security Agency (UKHSA) recommends that health professionals should use one resource for country-specific malaria recommendations to optimize the consistency of advice. 
• The UKHSA  prophylaxis guidelines are intended for UK-based travellers and may not be appropriate for people resident in endemic areas. For advice on prophylaxis for a person resident in an endemic area, seek expert advice from a travel specialist. Sources of expert advice include:
  • Malaria Reference Laboratory (MRL) — website www.malaria-reference.co.uk.
  • National Travel Health Network and Centre (NaTHNaC) — advice line for healthcare professionals (020 7383 7474) and website www.travelhealthpro.org.uk.
  • TRAVAX (Health Protection Scotland) website www.travax.nhs.uk.

How should I manage a person intending to travel to a malaria endemic area?

For people intending to travel to a malaria-endemic area:

• Advise avoidance of travel to malarious areas if the person is at high risk of severe or fatal malaria (for example pregnant women, children, the elderly [aged over 70 years] and those with complex comorbidities or immunosuppression). 
  • If travel is unavoidable, explain the risks malaria presents, and the risks and benefits of antimalarial prophylaxis. 
  • Emphasise the importance of rigorous personal protective measures and adherence to chemoprophylaxis. Emergency medical attention should be sought immediately if malaria infection is suspected. 
• Recommend personal protective measures to prevent mosquito (and other vector) bites. 
• Consider the need for chemoprophylaxis based on the risk assessment.  
  • If the person has HIV, discuss options for chemoprophylaxis with their HIV physician who will make the decision on choice of agent. 
  • Ensure that parents/carers understand the importance of ensuring that children take chemoprophylaxis properly and complete the full course — maximum recommended doses must not be exceeded as antimalarials can be particularly toxic to children. 
• Consider the need for standby emergency medication if the person is visiting a remote area and likely to be more than 24 hours away from medical care. 
• Give advice and provide written information about:
  • Risk factors for acquiring malaria such as: 
    • Exposure to infective bites — risk is increased by being outside between dusk and dawn (when Anopheles mosquitos are likely to bite), longer stays, and unscreened accommodation. 
    • Misconceptions about immunity — immunity acquired by people born in malarious countries is rapidly lost after migration to the UK. Having had malaria in the past does not protect from future attacks — effective personal protective measures and chemoprophylaxis are needed for all visits to endemic areas. 
  • The life-threatening nature of malaria and the importance of personal protective measures and chemoprophylaxis. 
  • The clinical features of malaria and the importance of prompt diagnosis and early treatment. 
    • Malaria can progress from mild to life-threatening disease within hours — if clinical features of malaria develop while travelling or up to one year after return, early diagnosis and treatment is essential. 
    • Children and pregnant women with malaria can deteriorate very rapidly and become critically ill — ensure that all involved in the care of children returning from malarious areas (such as family/carers, school, and healthcare contacts) are aware that urgent medical attention (including a blood test for malaria) is required if the child becomes unwell within a year of leaving the malarious area. 
    • For information on the clinical features of malaria, see the CKS topic on Malaria.
  • Patient information leaflets are available from the UK Health Security Agency:
    • Malaria: information for people travelling overseas — available in English, Bengali, Gujarati, Punjabi and Urdu.
    • Travelling overseas to visit friends and relatives?
    • Guidance: malaria factsheet.
• If uncertain about management, seek specialist advice: 
  
  • Advice for health care professionals on insect and tick bite avoidance is available from:
    • The TravelHealthPro website which contains resources from the National Travel Health Network and Centre (NaTHNaC).
  • Advice for health care professionals on malaria prophylaxis is available from:
    • Malaria Reference Laboratory (MRL).
    • National Travel Health Network and Centre (NaTHNaC).
    • TRAVAX (Health Protection Scotland).

What personal protective measures should I recommend?

Advise the person that the first line of defence against malaria infection (and other vector-borne diseases) is effective bite prevention. Advise people on the use of: 

• Physical barriers
  • Full-length, loose-fitting, light-coloured clothing with long sleeves, long trousers and socks if out of doors after sunset.
    • Clothing can be treated with insecticide (such as permethrin) or cotton clothing sprayed with DEET to reduce biting through clothing (duration of action will be short as DEET is volatile). 
  • Screening on doors, windows, eaves and other gaps in the building.
  • Bed nets treated with insecticide.
    • Insecticide-treated mosquito nets should be used if the person is sleeping outdoors or in unscreened accommodation. Insecticide helps prevent mosquitos biting through the net if the body touches the mesh. 
    • Long-lasting pyrethroid insecticide-impregnated nets have an expected useful life of at least 3 years. 
    • Standard nets need to be re-impregnated every 6 to 12 months (depending on how frequently the net is washed) to remain effective. 
    • Bed nets must be free of tears and tucked in under the mattress. 
• Chemical barriers
  • Advise the person to use a 50% DEET (N,N-Diethyl-meta-toluamide) based insect repellent first line on exposed areas of skin.
    • This is suitable for all people aged over 2 months. 
    • DEET can damage some types of plastic (such as watch straps, watch covers, and plastic jewellery) – the person should not allow these items to come into contact with DEET. 
    • If both sunscreen and DEET are required, DEET should be applied after the sunscreen. As DEET may induce a reduction in SPF — 30 to 50 SPF sunscreen should be applied to compensate for this. 
  • If DEET is not tolerated, or preferred, advise the person to use the highest strength available of either: 
    • Icaridin — provides repellent properties similar to DEET 20% with a comparable duration if it is also used at 20%. 
    • Eucalyptus citriodora oil, hydrated, cyclized — provides protection for several hours. 
    • 3-ethlyaminopropionate — this has a shorter duration of protection than DEET, but is still an effective repellent. 
• Avoidance measures — advise people to: 
  
  • Plan activities at times when there is reduced risk (for example, during the daytime). 
    • Dusk and dawn should be avoided.
  • Visit areas where transmission is less likely (for example, urban centres and highland areas). 
• Coils/electric vapourisers
  
  • If electricity is available, an electric pyrethroid vapouriser can be used during the night.
  • Mosquito coils containing insecticide can be burnt as an alternative to repel and kill mosquitoes but this is not recommended for indoor use. 
• Insecticide sprays 
  • The room should be sprayed before dusk with a knockdown insecticide, usually a pyrethroid (such as permethrin) to kill any mosquitoes which may have entered the accommodation during the day.

What chemoprophylaxis should I prescribe?

• If chemoprophylaxis is required (based on individual risk assessment):
  • Explain that a combination of mosquito avoidance and chemoprophylaxis will give significant protection against malaria, but no regime is 100% effective. 
  • Identify chemoprophylactic agents appropriate for the destination and person by:
    • Consulting the Public Health England or NaTHNaC  website should be checked regularly for clinical updates as recommendations may change over time even in minimal risk areas.
  • Discuss the advantages and disadvantages of appropriate chemoprophylaxis regimens with the person. 
  • Explain the dosing schedule (including the need to take the drug before, during and for some time after visiting a malarious area), adverse effects and any precautions with specific drugs (for example, avoidance of sun exposure with doxycycline). 
  • Recommend that chemoprophylaxis should be obtained from a reputable source in the UK before travel as some antimalarials purchased abroad may be fake or substandard. 
  • Explain the risks of discontinuation of anti-malarial drugs – fatal malaria has occurred in people who have stopped all chemoprophylaxis or changed to a less effective drug. 
    • If significant adverse events are experienced because of the chemoprophylactic agent, advice should be sought from an appropriately experienced healthcare professional regarding an effective alternative. 
• If the person discontinues chemoprophylaxis on or after return to UK due to adverse effects: 
  • No additional prophylactic drug is needed if suppressive prophylaxis (chloroquine, doxycycline, mefloquine) is discontinued before completing 4 weeks’ dosage post return.
  • The person must be warned that they are at increased risk of malaria compared with those who have completed the full regimen.
  • Advice the person to seek urgent medical attention if they become unwell in the first year after return — an urgent blood test for malaria is essential.
• Causal chemoprophylaxis (for example, primaquine) is directed at the liver stages of the malaria parasite, which takes approximately 7 days to develop — this prevents the parasite from infecting red blood cells. 
  • These agents need to be continued for 7 days after leaving the malarious area. 
  • Note: primaquine is not licensed in the UK.
• Suppressive chemoprophylaxis (for example chloroquine, doxycycline, and mefloquine) is directed at the red blood cell stage of the malaria parasite.  
  • These agents should be continued for 4 weeks after leaving the malarious area. 

When should I prescribe standby emergency medication?

• Standby emergency medication is intended for travellers who believe that they may have malaria — it is not a replacement for chemoprophylaxis. 
  • It is not required for most travellers but should be considered if the person is taking chemoprophylaxis and visiting remote areas which are not within 24 hours of medical facilities. 
  • Choose a recommended regimen based on The Advisory Committee on Malaria Prevention (ACMP) which can be found on the UK Health Security Agency  (UKHSA) website.
    • To reduce the risk of drug toxicity and resistance, the drug used for emergency standby medication should be different to the chemoprophylactic drug. 
  • Explain and provide written information on:
    • When to start the medication — standby emergency medication should be started within 24 hours of onset of fever and medical attention sought as soon as possible for a full assessment to exclude any other serious causes of fever. For further information on the clinical features of malaria, see the CKS topic on Malaria.
    • How the medication should be taken (including dosage, interval, and duration of treatment). What to do if vomiting occurs on taking the medication — a second full treatment dose of the antimalarial should be taken if vomiting occurs within 30 minutes of taking it (half-dose if vomiting occurs after 30–60 minutes). 
    • Possible adverse effects. 
    • How and when to restart chemoprophylaxis — on completion of the standby treatment course, antimalarial chemoprophylaxis should be restarted 1 week after taking the first treatment dose. If quinine is used for standby treatment, mefloquine prophylaxis should be restarted at least 12 hours after the last treatment dose. 
  • Explain that standby emergency medication is not a replacement for chemoprophylaxis and only a temporary measure. 
  • A patient information leaflet on emergency standby medication is available as part of the UKHSA publication Guidelines for malaria prevention in travellers from the UK: 2021.
    • Advise travelling companions to read the leaflet as well in case the person becomes ill and needs assistance to follow the advice.

Dose

• Chloroquine is the drug of choice for people travelling to areas with chloroquine-sensitive malaria (chloroquine-resistant malaria is widespread). Chloroquine:
  • Is available as a syrup or tablets and is usually taken as a single dose once a week, on the same day each week.
  • It should be started 1 week before entering an endemic area, continued throughout the time in the area and for 4 weeks after leaving the area.
  • Is considered safe for long-term use but eye examinations every 6 to 12 months should be considered after 6 years’ use for malaria prophylaxis. 
• The dose for adults is 310 mg (two 250 mg chloroquine phosphate tablets) once weekly. 
  • Alternatively, the liquid dose is 300 mg once weekly — 30 ml of chloroquine syrup 50 mg/5 ml. 
  • For adults who weigh less than 45 kg, the dose is 232.5 mg once weekly. 
  • Note: each 250 mg tablet contains 155 mg chloroquine base and syrup contains 50 mg/5 ml chloroquine base. The doses below relate to chloroquine base.
• For children, use body weight as a guide to calculate the dose:
  • Chloroquine 50 mg/5 ml syrup:  
    • Under 4.5 kg — 25 mg (2.5 ml) once weekly.
    • 4.5-7.9 kg — 50 mg (5 ml) once weekly.
    • 8.0-10.9 kg — 75 mg (7.5 ml) once weekly.
    • 11.0-14.9 kg — 100 mg (10 ml) once weekly.
    • 15.0-16.5 kg — 125 mg (12.5 ml) once weekly.
    • 16.6-24 kg — 150 mg (15 ml) once weekly. 
    • 25-44 kg — 225 mg (22.5 ml) once weekly.
    • 45 kg and above — 300 mg (30 ml) once weekly.
  • Chloroquine 155 mg tablets: 
    • Under 6 kg — 38.75 mg once weekly (one-quarter of a tablet).
    • 6–9 kg — 77.5 mg once weekly (half a tablet).
    • 10–15 kg — 116.25 mg once weekly (three-quarters of a tablet).
    • 16–24 kg — 155 mg once weekly (1 tablet).
    • 25–44 kg — 232.5 mg once weekly (1.5 tablets).
    • 45 kg and above — 310 mg once weekly (2 tablets).
• Chloroquine can be given from birth.
  • Chloroquine has a bitter taste and may need to be mixed with food to encourage the child to take it.
• Chloroquine is highly toxic in overdose, particularly in children. 
  • Overdose is extremely hazardous and difficult to treat. Life-threatening features include arrhythmias (which can have a very rapid onset) and convulsions (which can be intractable). 
  • If overdose occurs urgent advice from the National Poisons Information Service is essential.  

[ABPI, 2020; BNF, 2022; ABPI, 2022e] 

Contraindications and cautions

• Chloroquine is contraindicated in people:
  • With epilepsy.
  • With severe gastrointestinal disorders.
  • Taking amiodarone. 
• Chloroquine should be used with caution in:
  • Acute porphyrias — may precipitate severe symptoms.
  • Diabetes mellitus (may lower blood glucose).
  • G6PD deficiency — there may be a risk of haemolysis.
  • Hepatic impairment — particularly cirrhosis.
  • Neurological disorders. 
  • People at risk of prolonged QT interval.
  • People with psoriasis or myasthenia gravis — may exacerbate these conditions; avoid if possible.
  • Renal impairment — chloroquine is only partially excreted by the kidneys and reduction of the dose is not needed except in severe impairment.

[BNF, 2022; ABPI, 2022e]

Adverse effects

• Adverse effects include:
  • Blood — bone marrow failure, aplastic anaemia, agranulocytosis, thrombocytopenia, neutropenia, pancytopenia. 
  • Eye — blurred vision, diplopia, macular defects of colour vision, blindness.
  • Gastrointestinal — abdominal pain, constipation, diarrhoea, vomiting and nausea.
  • Psychiatric — insomnia, confusion, depression, aggression, delusion.
    • Cases of suicidal behaviour and psychiatric disorders have been reported in patients treated with chloroquine, including in people with no prior history of psychiatric disorders. Advise patients to seek medical advice promptly if they experience psychiatric symptoms during treatment. 
  • Skin and subcutaneous tissue — alopecia, erythema multiforme, drug reaction with eosinophilia and systemic symptoms syndrome (DRESS), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalised exanthematous pustulosis (AGEP), precipitation of psoriasis, and pruritus.
• Other adverse effects include:
  • Hypoglycaemia. 
  • Hypotension
  • Myopathy.
  • ECG changes.
• Chloroquine is very toxic in overdosage — it 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). 

[BNF, 2022; ABPI, 2022e]

Drug interactions

• Antacids may reduce the absorption of chloroquine — they should be taken at least 4 hours apart.
• Ciclosporin — increased risk of ciclosporin toxicity. Consider increasing monitoring of ciclosporin if chloroquine is started or stopped and adjust the ciclosporin dose as necessary.
• Drugs that prolong the QT interval, for example:
  • Amiodarone — if concurrent use is unavoidable consider ECG monitoring. 
  • Domperidone — avoid concurrent use.
  • Mizolastine — avoid concurrent use.
  • Macrolide antibiotics (such as azithromycin, clarithromycin) — if concurrent use is unavoidable, be alert for cardiac adverse effects, and warn patients to report any signs of cardiac events (palpitations, fainting, chest pain, unexplained breathlessness).
  • Tricyclic antidepressants (such as amitriptyline) — consider ECG monitoring in people predisposed to QT prolongation. 
  • Mefloquine. 
• Drugs that cause hypokalaemia (for example, corticosteroids, aminophylline, thiazide diuretics) — increased risk of torsades de pointes. Monitor potassium levels closely. 
• Penicillamine — may increase the risk of haematological toxicity.
• Rabies vaccine — the antibody response may be reduced by chloroquine. Vaccination should take place before starting chloroquine.  
• Cholera vaccine — the antibody response is reduced. Avoid concurrent use. Start chloroquine prophylaxis no sooner than 8 days after vaccination with oral cholera vaccines. 
• Remdesivir — the effects of remdesivir may be reduced if taken concurrently with chloroquine. Avoid concurrent use.  

[Preston, 2023]

Pregnancy and breastfeeding

• Pregnancy 
  • The UK Teratology Information Service (UKTIS) found no conclusive evidence (from limited available studies) that chloroquine use in pregnancy is associated with increased risk of structural malformation or other adverse outcomes such as spontaneous abortion, stillbirth or low infant birth weight. It advises that it should not be withheld on the account of pregnancy as the known risks of maternal malaria infection are likely to be greater than any potential risks to the fetus from the drug. This view is also held by the manufacturers. 
• Breastfeeding
  • Chloroquine is present in breastmilk, but the amount is probably too small to be harmful.

[UKTIS, 2019; BNF, 2022; ABPI, 2022e]

Dose

• A checklist should be used prior to mefloquine administration to ensure all contraindications and cautions are identified. For further information see the manufacturer's Checklist for Healthcare Professionals. 
• Mefloquine should be started 2 to 3 weeks before entering a malarious area (to ascertain if there are any adverse effects) and continued until 4 weeks after leaving the area. 
• It can be safely used for up to 3 years, but the manufacturer suggests periodic checks on liver function and eye assessments should be taken if mefloquine is used for a prolonged period. 
  • Any person taking mefloquine presenting with a visual disorder should be referred to a specialist as chemoprophylaxis may need to be stopped.
• For adults, the dose is 250 mg once weekly. 
  • For adults who weigh less than 45 kg, the dose is 187.5 mg. 
• For children, use body weight as a guide to calculate the dose: 
  • 5–15.9 kg — 62.5 mg (one-quarter of a tablet) once weekly. 
  • 16.0–24.9 kg — 125 mg (one-half of a tablet) once weekly.
  • 25.0–44.9 kg — 187.5 mg (three-quarters of one tablet) once weekly.
  • 45 kg and over — 250 mg once weekly.

 [BNF, 2022]

Contraindications and cautions

• Do not prescribe mefloquine in people with:
  • A current or previous history of depression, generalized anxiety disorder, psychosis, schizophrenia, suicide attempts, suicidal thoughts, self-endangering behaviour or any other psychiatric disorder, epilepsy or convulsions of any origin. 
  • A history of convulsions (if used for standby treatment).
  • A history of Blackwater fever.
  • Severe liver impairment.
• Also do not prescribe mefloquine to:
  • Infants under 5 kg weight.
• Prescribe mefloquine with caution in people with: 
  • Cardiac conduction abnormalities.
  • Epilepsy.
  • Infants aged less than 3 months.
  • Traumatic brain injury.
• Also consider the following: 
  • Diving — some diving centres do not permit people taking mefloquine to dive. Mefloquine can lower the seizure threshold and its adverse effects could potentially be confused with decompression or narcosis events. It may be best to avoid for diving holidays.
  • Military personnel — the Ministry of Defence has guidelines for malaria prevention specific to military personnel and civilian practitioners asked to give malaria prevention advice for military travellers should liaise with the Defence Medical Services.
  • Pilots — the UK Civil Aviation Authority advises that mefloquine should not be administered to pilots, although there is no evidence that mefloquine impairs function. 

[ABPI, 2022b; BNF, 2022]

Adverse effects

• Gastrointestinal — abdominal pain, diarrhoea, nausea, vomiting. 
• Nervous system — dizziness, headache.
• Psychiatric — mefloquine may induce psychiatric symptoms such as anxiety disorders, paranoia, depression, hallucinations and psychosis.
  • The manufacturer advises that psychiatric symptoms such as insomnia, abnormal dreams/nightmares, acute anxiety, depression, restlessness or confusion have to be regarded as prodromal for a more serious event. Cases of suicide, suicidal thoughts and self-endangering behaviour such as attempted suicide have been reported.
  • Advise people that if these reactions or changes to their mental state occur during mefloquine use, to stop taking it and seek medical advice immediately. 
  • Note: adverse reactions may also occur after discontinuation of mefloquine. 
• Other common adverse effects include:
  • Pruritus.
  • Vertigo.
  • Visual impairment.

 [ABPI, 2022b; BNF, 2022]

Drug interactions

• Anticonvulsants and drugs lowering the epileptogenic threshold — concurrent use of mefloquine with anticonvulsants may reduce blood levels of anticonvulsants leading to loss of seizure control. Dose adjustments may be necessary. Concurrent use with drugs known to reduce the seizure threshold (for example, antidepressants, antipsychotics) may increase the risk of convulsions.   
• Drugs that inhibit the CYP3A4 enzyme (for example, fluconazole) — mefloquine levels may be increased, increasing the risk of QT interval prolongation. Monitor for adverse effects. 
• Halofantrine — concentrations of halofantrine may be increased, increasing the risk of arrhythmias due to QT prolongation. Avoid concurrent use and for 15 weeks after the last dose of mefloquine. 
• Other drugs that prolong the QT interval (for example, astemizole, mizolastine) — concurrent use is not contraindicated, however, caution is advised especially in people predisposed to cardiovascular problems. 
• Rifampicin — exposure to mefloquine reduced. Avoid concurrent use.
• Typhoid vaccine — the effectiveness of live oral typhoid vaccine may be reduced. The manufacturer recommends that vaccinations should be completed at least 3 days before the first dose of mefloquine.

[Preston, 2023]

Pregnancy and breastfeeding

• Pregnancy 
  • The manufacturer advises that limited data in pregnancy indicate no adverse effects, and that due to the seriousness of malaria during pregnancy pregnant women or women who wish to become pregnant should be discouraged from travelling in endemic areas. Prophylactic treatment with mefloquine may be considered regardless of the term of pregnancy.
  • UKHSA advise that mefloquine can be used in all trimesters for travellers to high-risk areas, but urges caution in the first trimester, although due to the potential severity of falciparum malaria in pregnant women, advises that use is generally justified for areas with high risk of falciparum malaria (such as sub-Saharan Africa). 
• Breastfeeding
  • Mefloquine is present in breastmilk, but there is minimal risk to the infant and it is safe to use in women who are breastfeeding. 

[ABPI, 2022b; BNF, 2022; UKHSA, 2024]

Dose

• Doxycycline should be started 1 or 2 days before entering an endemic area and be continued until 4 weeks after leaving the area. 
• Doxycycline is available as 50 mg or 100 mg capsules and 100 mg dispersible tablets.
• The capsules and solution of dispersible tablets should be swallowed with plenty of fluid in either the resting or standing position. The person should be advised not to lie down for at least 1 hour after ingestion to reduce the likelihood of oesophageal irritation and ulceration.
  • If gastric irritation occurs, it is recommended that doxycycline is taken with food or milk.
• The dose for adults and children aged over 12 years is 100 mg once daily.  
  • Doxycycline is contraindicated in children aged under 12 years irrespective of weight.

[ABPI, 2021; BNF, 2022]

Pregnancy and breastfeeding

• Pregnancy 
  • The manufacturer advises that use during pregnancy is contraindicated.
  • The UK National Teratology Information Service (UKTIS) states that doxycycline is best avoided for antimalarial prophylaxis during pregnancy. However, if required before 15 weeks' gestation it should not be withheld if other options are unsuitable. The course of doxycycline, including the 4 weeks after travel, must be completed before 15 weeks’ gestation.
• Breastfeeding
  • The Advisory Committee on Malaria Prevention (ACMP) advises that doxycycline should not be used in breastfeeding unless other options are unsuitable, and its use is felt to be essential.
• For further prescribing information section on Doxycycline in the CKS topic on Chest infection - adult.

[ABPI, 2021; BNF, 2022]