Mefloquine

Agranulocytosis and aplastic anemia have been reported.

Mefloquine may cause alterations in the ECG including sinus bradycardia, sinus arrhythmia, first-degree AV block, QT-interval prolongation, and abnormal T waves. Use caution or avoid concomitant use of agents known to cause QT-interval prolongation (eg, halofantrine, quinine, quinidine).

Hypersensitivity reactions have occurred.

May cause neuropsychiatric adverse effects that can persist after mefloquine has been discontinued. During prophylactic use, if symptoms occur, discontinue therapy and substitute an alternative medication. Symptoms may develop early in the course of therapy. Due to the difficulty in identifying these symptoms in infants and children, monitor closely especially in pediatric patients. Psychiatric symptoms may include anxiety, paranoia, depression, hallucinations, and psychosis. Suicidal ideation and suicide have also been reported. Neurologic symptoms of dizziness or vertigo, tinnitus, and loss of balance may also occur and have been reported to be permanent in some cases. During prophylactic use, the occurrence of psychiatric symptoms such as acute anxiety, depression, restlessness, or confusion may be a prodrome to more serious neuropsychiatric adverse reactions. Use caution in activities requiring alertness and fine motor coordination (eg, driving, piloting planes, operating machinery) with neurologic symptoms. Disease-related concerns:

Use with caution in patients with significant cardiac disease; ECG changes (eg, sinus bradycardia, sinus arrhythmia, first-degree AV block, QT-interval prolongation, abnormal T waves) have been reported.

Use with caution in patients with hepatic impairment; elimination may be prolonged.

Do not prescribe for prophylaxis in patients with major psychiatric disorders including patients with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia; use is contraindicated in these patients. Use with caution in patients with a previous history of depression.

Eye disorders (including optic neuropathy and retinal disorders) have been reported during treatment. If visual symptoms develop during treatment, prompt ophthalmologic evaluation is warranted; discontinuation of therapy may be necessary.

Appropriate use: In cases of life-threatening, serious, or overwhelming malaria infections due to Plasmodium falciparum, patients should be treated with intravenous antimalarial drug. Mefloquine may be given orally to complete the course.

Appropriate use: In cases of acute Plasmodium vivax infection treated with mefloquine, patients should subsequently be treated with an 8-aminoquinoline derivative (eg, primaquine) to avoid relapse.

When using for treatment, use with caution in patients with a history of seizures; may increase risk of seizures. Prophylactic use is contraindicated in patients with seizure disorder. Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

Early vomiting leading to treatment failure in children has been reported in some studies; consider alternate therapy if a second dose is not tolerated. Other warnings/precautions:

Not recommended for the treatment of malaria acquired in Southeast Asia due to drug resistance (CDC 2013b).

If mefloquine is to be used for a prolonged period, liver function tests, evaluations for neuropsychiatric effects, and ophthalmic examinations should be performed periodically.