Mefloquine

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Mefloquine, sold under the brand name Lariam among others, is a medication used to prevent or treat malaria.<ref name=AHFS2015>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> When used for prevention it is typically started before potential exposure and continued for several weeks after potential exposure.<ref name=AHFS2015/> It can be used to treat mild or moderate malaria but is not recommended for severe malaria.<ref name=AHFS2015/> It is taken by mouth.<ref name=AHFS2015/>

Common side effects include vomiting, diarrhea, headaches, sleep disorders, and a rash.<ref name=AHFS2015/> Serious side effects include potentially long-term mental health problems such as depression, hallucinations, and anxiety and neurological side effects such as poor balance, seizures, and ringing in the ears.<ref name=AHFS2015/> It is therefore not recommended in people with a history of mental health problems or epilepsy.<ref name=AHFS2015/> It appears to be safe during pregnancy and breastfeeding.<ref name="Drugs.com pregnancy">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Mefloquine was developed by the United States Army in the 1970s and came into use in the mid-1980s.<ref name=Croft07>Template:Cite journal</ref><ref>Template:Cite book</ref><ref>Template:Cite book</ref> It is on the World Health Organization's List of Essential Medicines.<ref name="WHO21st">Template:Cite book</ref><ref name="WHO22nd">Template:Cite book</ref> It is available as a generic medication.<ref name=AHFS2015/>

Medical uses

File:Lariam.JPG

Mefloquine (Lariam) 250mg tablets

Mefloquine is used to both prevent and treat certain forms of malaria.<ref name=AHFS/>

Malaria prevention

Mefloquine is useful for the prevention of malaria in all areas except for those where parasites may have resistance to multiple medications,<ref name=Review10>Template:Cite journal</ref> and is one of several anti-malarial medications recommended by the United States Centers for Disease Control and Prevention for this purpose. It is also recommended by the Infectious Disease Society of America for malaria prophylaxis as a first or second-line agent, depending on resistance patterns in the malaria found in the geographic region visited.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It is typically taken for one to two weeks before entering an area with malaria.<ref name=AHFS/> Doxycycline and atovaquone/proguanil provide protection within one to two days and may be better tolerated.<ref name=Review99>Template:Cite journal</ref><ref>Template:Cite journal</ref> If a person becomes ill with malaria despite prophylaxis with mefloquine, the use of halofantrine and quinine for treatment may be ineffective.<ref name=Prodguide>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>Template:Rp

Malaria treatment

Mefloquine is used as a treatment for chloroquine-sensitive or resistant Plasmodium falciparum malaria, and is deemed a reasonable alternative for uncomplicated chloroquine-resistant Plasmodium vivax malaria.<ref name=AHFS>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=Prodguide/> It is one of several drugs recommended by the United States' Centers for Disease Control and Prevention.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It is not recommended for severe malaria infections, particularly infections from P. falciparum, which should be treated with intravenous antimalarials.<ref name=AHFS/><ref name=Prodguide/> Mefloquine does not eliminate parasites in the liver phase of the disease, and people with P. vivax malaria should be treated with a second drug that is effective for the liver phase, such as primaquine.<ref name=Prodguide/>Template:Rp

Resistance to mefloquine

Resistance to mefloquine is common around the west border in Cambodia and other parts of Southeast Asia.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The mechanism of resistance is by increase in Pfmdr1 copy number.<ref name="Price2004">Template:Cite journal</ref>

Contraindications

Mefloquine is contraindicated in those with a previous history of seizures or a recent history of psychiatric disorders.<ref name="AHFS" />

Pregnancy and breastfeeding

Available data suggests that mefloquine is safe and effective for use by pregnant women during all trimesters of pregnancy,<ref name=CDC2019>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and it is widely used for this indication.<ref name="González R, Hellgren U, Greenwood B, Menéndez C 2014 75">Template:Cite journal</ref> In pregnant women, mefloquine appears to pose minimal risk to the fetus,<ref name="González R, Hellgren U, Greenwood B, Menéndez C 2014 75"/><ref>Template:Cite journal</ref> and is not associated with increased risk of birth defects or miscarriages.<ref>Template:Cite journal</ref> Compared to other malaria chemoprophylaxis regimens, however, mefloqinone may produce more side effects in non-pregnant travelers.

Mefloquine is also safe and effective for use during breastfeeding,<ref name=CDC2019/> though it appears in breast milk in low concentrations.<ref name="Review10" /><ref name=Prodguide/>Template:Rp The World Health Organization (WHO) gives approval for the use of mefloquine in the second and third trimesters of pregnancy and use in the first trimester does not mandate termination of pregnancy.<ref name="Review10" />

Adverse effects

Common side effects include vomiting, diarrhea, headaches, and a rash.<ref name=AHFS2015/> Severe side effects requiring hospitalization are rare,<ref name=Review10/> but include mental health problems such as depression, hallucinations, anxiety and neurological side effects such as poor balance, seizures, and ringing in the ears.<ref name=AHFS2015/> Mefloquine is therefore not recommended in people with a history of psychiatric disorders or epilepsy.<ref name=AHFS2015/>

Liver function tests should be performed during long-term administration of mefloquine.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Alcohol use should be avoided during treatment with mefloquine.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Neurologic and psychiatric

In 2013, the U.S. Food and Drug Administration (FDA) added a boxed warning to the prescription label of mefloquine regarding the potential for neuropsychiatric side effects that may persist even after discontinuing administration of the medication.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In 2013 the FDA stated "Neurologic side effects can occur at any time during drug use, and can last for months to years after the drug is stopped or can be permanent."<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Neurologic effects include dizziness, loss of balance, seizures, and tinnitus. Psychiatric effects include nightmares, visual hallucinations, auditory hallucinations, anxiety, depression, unusual behavior, and suicidal ideations.

Central nervous system events requiring hospitalization occur in about one in 10,000 people taking mefloquine for malaria prevention, with milder events (e.g., dizziness, headache, insomnia, and vivid dreams) in up to 25%.<ref>Template:Cite journal</ref> When some measure of subjective severity is applied to the rating of adverse events, about 11–17% of travelers are incapacitated to some degree.<ref name=Review99/>

Cardiac

Mefloquine may cause abnormalities with heart rhythms that are visible on electrocardiograms. Combining mefloquine with other drugs that cause similar effects, such as quinine or quinidine, can increase these effects. Combining mefloquine with halofantrine can cause significant increases in QTc intervals.<ref name=Prodguide/>Template:Rp

Pharmacology

Pharmacodynamics

The mechanism of action of mefloquine is unclear and several competing hypotheses exist.<ref>Template:Cite book</ref>

Off-target activities

Mefloquine has known off-target activities.<ref name="JanowskyEshleman2014">Template:Cite journal</ref><ref name="HoldenSlivickiDahl2015">Template:Cite journal</ref> This includes affinity for the serotonin 5-HT_2A receptor and to a lesser extent for the serotonin 5-HT_2C receptor, but not for the serotonin 5-HT_1A receptor.<ref name="JanowskyEshleman2014" /><ref name="HoldenSlivickiDahl2015" /> Mefloquine acts as a partial agonist of both the serotonin 5-HT_2A and 5-HT_2C receptors, similarly to serotonergic psychedelics like LSD, DOM, and DMT.<ref name="JanowskyEshleman2014" /><ref name="HoldenSlivickiDahl2015" /> It also binds to the serotonin transporter and acts as a serotonin reuptake inhibitor, acts as a serotonin 5-HT₃ receptor antagonist, and shows affinity for the dopamine D₃ receptor, among other actions.<ref name="JanowskyEshleman2014" /><ref name="HoldenSlivickiDahl2015" /><ref name="StykaSavitz2020">Template:Cite book</ref><ref name="ThompsonLummis2008">Template:Cite journal</ref> These properties of mefloquine, especially serotonin 5-HT_2A receptor agonism, may be involved in the neurological and psychiatric adverse effects such as visual hallucinations that have been reported with its use particularly at high doses.<ref name="JanowskyEshleman2014" /><ref name="HoldenSlivickiDahl2015" /> Mefloquine is a drug that is thought to have potential antiepilectic effects due to its ability to non-specifically block connexin hemi-channels and pannexons.<ref name="Wang Z et Al.">Template:Cite journal</ref><ref name="Angus JA et Al.">Template:Cite journal</ref>

Pharmacokinetics

Mefloquine is metabolized primarily through the liver. Its elimination in persons with impaired liver function may be prolonged, resulting in higher plasma levels and an increased risk of adverse reactions. The mean plasma elimination half-life of mefloquine is between 2 and 4Template:Nbspweeks. Total clearance is through the liver, and the primary means of excretion is through the bile and feces, as opposed to only 4% to 9% excreted through the urine. During long-term use, the plasma half-life remains unchanged.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Chemistry

File:Tryptamine and mefloquine structures.png

Chemical structures of tryptamine and mefloquine.

Mefloquine is a chiral molecule with two asymmetric carbon centres, which means it has four different stereoisomers. The drug is currently manufactured and sold as a racemate of the (R,S)- and (S,R)-enantiomers by Hoffmann-La Roche, a Swiss pharmaceutical company. Essentially, it is two drugs in one. Plasma concentrations of the (–)-enantiomer are significantly higher than those for the (+)-enantiomer, and the pharmacokinetics between the two enantiomers are significantly different. The (+)-enantiomer has a shorter half-life than the (–)-enantiomer.<ref name=Review99/> Specifically it is used as mefloquine hydrochloride.

The chemical structure of mefloquine is similar to that of tryptamine and its derivatives.<ref name="PubChem">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> However, whereas tryptamine is an indolylethylamine, mefloquine is a quinolinylethylamine.<ref name="PubChem" /> Mefloquine's structure is also particularly similar to that of 10,11-secoergoline (α,N-tetramethylenetryptamine).<ref name="PubChem" />

History

Mefloquine was formulated at Walter Reed Army Institute of Research (WRAIR) in the 1970s shortly after the end of the Vietnam war. Mefloquine was number 142,490 of a total of 250,000 antimalarial compounds screened during the study.<ref name=Croft07/>

Mefloquine was the first Public-Private Venture (PPV) between the US Department of Defense and a pharmaceutical company. WRAIR transferred all its phase I and phase II clinical trial data to Hoffman-LaRoche and Smith Kline. FDA approval as a treatment for malaria was swift. Most notably, phase III safety and tolerability trials were skipped.<ref name=Croft07/>

The drug was first approved in Switzerland in 1984 by Hoffmann-LaRoche,<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> who brought it to market with the name Lariam.<ref name=gnml/>

However, mefloquine was not approved by the FDA for prophylactic use until 1989. This approval was based primarily on compliance, while safety and tolerability were overlooked.<ref name=Croft07/> Because of the drug's very long half-life, the Centers for Disease Control originally recommended a mefloquine dosage of 250 mg every two weeks; however, this caused an unacceptably high malaria rate in the Peace Corps volunteers who participated in the approval study, so the drug regimen was switched to once a week.<ref name=Review99/>

By 1991, Hoffman was marketing the drug on a worldwide basis.<ref name="gnml">Template:Cite news</ref>

By the 1992 UNITAF, Canadian soldiers were being prescribed the drug en masse.<ref name="canvet">Template:Cite news</ref>

By 1994, medical professionals were noting "severe psychiatric side effects observed during prophylaxis and treatment with mefloquine", and recommending that "the absence of contraindications and minor side effects during an initial course of mefloquine should be confirmed before another course is prescribed."<ref>Template:Cite journal</ref> Other doctors at the University Hospital of Zurich noted in a case of "a 47-year-old, previously healthy Japanese tourist" who had severe neuropsychiatric side-effects from the drug that<ref>Template:Cite journal</ref> Template:Cquote

The first randomized, controlled trial on a mixed population was performed in 2001. Prophylaxis with mefloquine was compared to prophylaxis with atovaquone-proguanil. Roughly 67% of participants in the mefloquine arm reported greater than or equal to one adverse event, versus 71% in the atovaquone-proguanil arm. In the mefloquine arm, 5% of the users reported severe events requiring medical attention, versus 1.2% in the atovaquone-proguanil arm.<ref name=Croft07/><ref>Template:Cite journal</ref>

In August 2009, Roche stopped marketing Lariam in the United States.<ref name=deipo/>

Retired soldier Johnny Mercer, who was later appointed Minister for Veterans Affairs by Boris Johnson, told in 2015 that he had received "a letter about once or twice a week" about ill-effects from the drug.<ref name="tmgs">Template:Cite news</ref> In July 2016, Roche took this brand off the market in Ireland.<ref name=deipo/>

Military

Template:See also In 2006, the Australian military deemed mefloquine "a third-line drug" alternative, and over the five years from 2011 only 25 soldiers had been prescribed the drug, and only in cases of their intolerance for other alternatives.<ref name=deipo/> Between 2001 and 2012, 16,000 Canadian soldiers sent to Afghanistan were given the drug as a preventative measure.<ref name=deipo/> In 2013, the US Army banned mefloquine from use by its special forces such as the Green Berets.<ref name=deipo/> In autumn 2016, the UK military followed suit with their Australian peers after a parliamentary inquiry into the matter revealed that it can cause permanent side effects and brain damage.<ref name=deipo/>

In early December 2016, the German defence ministry removed mefloquine from the list of medications it would provide to its soldiers.<ref name="deipo">Template:Cite news</ref>

In autumn 2016, Canadian Surgeon General Brigadier General Hugh Colin MacKay told a parliamentary committee that faulty science supported the assertion that the drug has indelible noxious side effects. An expert from Health Canada named Barbara Raymond told the same committee that the evidence she had read failed to support the conclusion of indelible side effects.<ref name=deipo/> Canadian soldiers who took mefloquine when deployed overseas have claimed they have been left with ongoing mental health problems.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

In 2020 the UK Ministry of Defence (MoD) admitted to a breach of duty regarding the use of Mefloquine.<ref>Template:Cite news</ref> by acknowledging numerous instances of failure to assess the risks and warn of potential side effects of the drug.

Research

In June 2010, the first case report appeared of a progressive multifocal leukoencephalopathy being successfully treated with mefloquine. Mefloquine can also act against the JC virus. Administration of mefloquine seemed to eliminate the virus from the patient's body and prevented further neurological deterioration.<ref>Template:Cite journal</ref>

Mefloquine alters cholinergic synaptic transmission through both postsynaptic<ref>Template:Cite journal</ref> and presynaptic actions.<ref>Template:Cite journal</ref> The postsynaptic action to inhibit acetylcholinesterase changes transmission across synapses in the brain.<ref>Template:Cite journal</ref>

Further reading

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External links

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