Atovaquone and Proguanil Hydrochloride and Nicotine

• Generic Name: atovaquone / proguanil
• Dosage Forms: n.a.
• Other Brand Names: Malarone, Malarone Pediatric

Prevention (prophylaxis) of malaria caused by Plasmodium falciparum (including chloroquine-resistant P. falciparum).

Recommended by CDC and others as a drug of choice for prophylaxis in those traveling to areas where chloroquine-resistant P. falciparum malaria has been reported; also can be used for prophylaxis in those traveling to areas where chloroquine-resistant P. falciparum has not been reported.

Risk of acquiring malaria varies substantially from traveler to traveler and from region to region (even within a single country) because of differences in intensity of malaria transmission within the various regions and season, itinerary, duration, and type of travel. Malaria transmission occurs in large areas of Africa, Central and South America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Mosquito avoidance measures must be used in conjunction with prophylaxis since no drug is 100% effective in preventing malaria.

Choice of antimalarial for prophylaxis depends on traveler’s risk of acquiring malaria in area(s) visited, risk of exposure to drug-resistant P. falciparum, other medical conditions (e.g., pregnancy), cost, and potential adverse effects.

Active only against asexual erythrocytic forms of Plasmodium (not exoerythrocytic stages) and cannot prevent delayed primary attacks or relapse of P. ovale or P. vivax malaria or provide a radical cure; terminal prophylaxis with 14-day regimen of primaquine may be indicated in addition to mefloquine prophylaxis if travelers were exposed in areas where P. ovale or P. vivax is endemic.

Information on risk of malaria in specific countries and mosquito avoidance measures and recommendations regarding whether prevention of malaria indicated and choice of antimalarials for prevention are available from CDC.

Presumptive Self-treatment of Malaria

Presumptive self-treatment of malaria in travelers.

In consultation with their health-care provider, some travelers (e.g., those who elect not to use prophylaxis, those who use a prophylaxis regimen that may not have optimal efficacy, those who use effective prophylaxis but will be in very remote areas) may elect to take along an appropriate antimalarial to use for presumptive self-treatment if necessary.

Self-treatment in these situations should be initiated promptly in the event of an influenza-like illness (e.g., fever, chills) if professional medical carenot readily available.

CDC and other experts recommend fixed combination of atovaquone and proguanil (atovaquone/proguanil) or fixed combination of artemether and lumefantrine (artemether/lumefantrine) for presumptive self-treatment of malaria.

Presumptive self-treatment of possible malarial infection is a temporary measure; it is imperative that a professional medical evaluation be obtained as soon as possible.

Treatment of Uncomplicated Malaria

Treatment of acute, uncomplicated malaria caused by P. falciparum (including chloroquine-resistant P. falciparum) or chloroquine-resistant P. vivax.

For treatment of uncomplicated malaria caused by chloroquine-resistant P. falciparum or treatment of uncomplicated malaria when plasmodial species not identified, CDC recommends atovaquone/proguanil, artemether/lumefantrine, or regimen of quinine in conjunction with doxycycline, tetracycline, or clindamycin.

For treatment of uncomplicated malaria caused by chloroquine-susceptible P. falciparum, P. malariae, or P. knowlesi or treatment of uncomplicated malaria when plasmodial species not identified and infection acquired in areas where chloroquine resistance not reported, CDC recommends chloroquine (or hydroxychloroquine). Alternatively, CDC states that any of the regimens recommended for treatment of uncomplicated chloroquine-resistant P. falciparum malaria may be used if preferred, more readily available, or more convenient.

For treatment of uncomplicated malaria caused by chloroquine-resistant P. vivax, CDC recommends regimen of quinine and doxycycline (or tetracycline) given in conjunction with primaquine, atovaquone/proguanil given in conjunction with primaquine, or mefloquine given in conjunction with primaquine.

Pediatric patients with uncomplicated malaria generally can receive same treatment regimens recommended for adults using age- and weight-appropriate drugs and dosages. For treatment of uncomplicated chloroquine-resistant P. falciparum in children <8 years of age, atovaquone/proguanil or artemether/lumefantrine usually recommended, but mefloquine can be considered if no other options available. For treatment of chloroquine-resistant P. vivax malaria in children <8 years of age, CDC recommends mefloquine given in conjunction with primaquine. Alternatively, if mefloquine not available or not tolerated and if potential benefits outweigh risks, atovaquone/proguanil or artemether/lumefantrine can be used for treatment of chloroquine-resistant P. vivax in this age group.

Because atovaquone/proguanil active only against asexual erythrocytic forms of Plasmodium (not exoerythrocytic stages), 14-day regimen of primaquine indicated to eradicate hypnozoites and prevent delayed primary attacks or relapse and provide a radical cure whenever atovaquone/proguanil used for treatment of P. ovale or P. vivax malaria.

Not indicated for treatment of severe or complicated malaria.

Assistance with diagnosis or treatment of malaria is available from CDC Malaria Hotline at 770-488-7788 or 855-856-4713 from 9:00 a.m. to 5:00 p.m. Eastern Standard Time or CDC Emergency Operation Center at 770-488-7100 after hours and on weekends and holidays.