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Reinhard MJ, Chester JE, Breneman CB, Samuel IBH, Prisco MK, Vincent TD, Rumm PD, Smith SR, Barrett JP. A Cross-sectional Cohort Study to Assess Long-term Neurocognitive and Psychiatric Symptoms of Mefloquine Use in Veterans. Mil Med 2023; 188:689-696. [PMID: 35446430 DOI: 10.1093/milmed/usac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/11/2022] [Accepted: 04/07/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION To evaluate the associations between neurocognitive and psychiatric health outcomes with mefloquine or any antimalarial exposure. MATERIALS AND METHODS Medical records were systematically reviewed to identify veterans that indicated antimalarial medication use. Linear regression was performed to examine associations between mefloquine/antimalarial exposure and health outcomes. The mefloquine-exposed group was further compared with normative populations for the same health outcomes. RESULTS In the adjusted models, no significant differences were noted between the two exposure groups and the unexposed group for any of the health measures (P-value > 0.05). When compared to normative population samples, the mefloquine-exposed group had poorer health and greater neurobehavioral symptom severity or cognitive complaints. CONCLUSION This study suggests that mefloquine use by veterans referred for intensive evaluation of their military deployment exposures and health was not associated with increased, long-term, neurocognitive/psychiatric symptoms compared to unexposed veterans.
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Affiliation(s)
- Matthew J Reinhard
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
- Department of Psychiatry, Georgetown University Medical School, Washington, DC 20007, USA
| | - Jeremy E Chester
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
| | - Charity B Breneman
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD, USA
| | - Immanuel B H Samuel
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD, USA
| | - Michelle K Prisco
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
| | - Terra D Vincent
- Department of Veterans Affairs, Health Outcomes Military Exposures (HOME), Washington, DC 20420, USA
| | - Peter D Rumm
- Department of Veterans Affairs, Health Outcomes Military Exposures (HOME), Washington, DC 20420, USA
| | - Shanna R Smith
- Department of Veterans Affairs, Health Outcomes Military Exposures (HOME), Washington, DC 20420, USA
| | - John P Barrett
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422 , USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
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Jozefowicz-Korczynska M, Pajor A, Lucas Grzelczyk W. The Ototoxicity of Antimalarial Drugs-A State of the Art Review. Front Neurol 2021; 12:661740. [PMID: 33959089 PMCID: PMC8093564 DOI: 10.3389/fneur.2021.661740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/04/2021] [Indexed: 11/19/2022] Open
Abstract
This review summarizes current knowledge about the occurrence of hearing and balance disorders after antimalarial drugs treatment. It also examines the clinical applications of antimalarials, their mechanisms behind this ototoxicity and how it can be monitored. It includes studies with larger numbers of patients and those in which auditory function was assessed using audiological tests. Some antimalarials have been repurposed for other conditions like autoimmune disorders, rheumatic diseases, some viral diseases and cancers. While old antimalarial drugs, such as quinoline derivatives, are known to demonstrate ototoxicity, a number of new synthetic antimalarial agents particularly artemisinin derivatives, demonstrate unknown ototoxicity. Adverse audiovestibular effects vary depending on the medication itself, its dose and route of administration, as well as the drug combination, treated disease and individual predispositions of the patient. Dizziness was commonly reported, while vestibular symptoms, hearing loss and tinnitus were observed much less frequently, and most of these symptoms were reversible. As early identification of ototoxic hearing loss is critical to introducing possible alternative treatments with less ototoxic medications, therefore monitoring systems of those drugs ototoxic side effects are much needed.
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Affiliation(s)
- Magdalena Jozefowicz-Korczynska
- Balance Disorders Unit, Otolaryngology Department, The Norbert Barlicki Memorial Teaching Hospital, Medical University of Lodz, Lodz, Poland
| | - Anna Pajor
- Department of Otolaryngology, Head and Neck Oncology, The Norbert Barlicki Memorial Teaching Hospital, Medical University of Lodz, Lodz, Poland
| | - Weronika Lucas Grzelczyk
- Balance Disorders Unit, Otolaryngology Department, The Norbert Barlicki Memorial Teaching Hospital, Medical University of Lodz, Lodz, Poland
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3
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Nevin RL. Induced Hypoglossal Dysfunction as a Cause of Obstructive Sleep Apnea in Mefloquine-Exposed Veterans. Laryngoscope 2020; 130:E949. [PMID: 32562555 DOI: 10.1002/lary.28856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 11/12/2022]
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4
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Nevin RL. Mefloquine exposure as a cause of sleep disorders among US military personnel and veterans. Sleep 2019; 42:5564316. [PMID: 32463894 DOI: 10.1093/sleep/zsz183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Remington L Nevin
- Office of the Executive Director, The Quinism Foundation, White River Junction, VT
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5
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Tickell-Painter M, Saunders R, Maayan N, Lutje V, Mateo-Urdiales A, Garner P. Deaths and parasuicides associated with mefloquine chemoprophylaxis: A systematic review. Travel Med Infect Dis 2017; 20:5-14. [DOI: 10.1016/j.tmaid.2017.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/16/2017] [Accepted: 10/18/2017] [Indexed: 11/28/2022]
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Nevin RL. A serious nightmare: psychiatric and neurologic adverse reactions to mefloquine are serious adverse reactions. Pharmacol Res Perspect 2017; 5:e00328. [PMID: 28805982 PMCID: PMC5684859 DOI: 10.1002/prp2.328] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 11/10/2022] Open
Abstract
Mefloquine (originally marketed as Lariam) is a neurotoxic quinoline derivative antimalarial drug that is known to cause serious and potentially lasting neuropsychiatric adverse reactions. Since 2013, drug regulators in several jurisdictions, including the United States, the United Kingdom, Ireland, and Canada, have required their mefloquine labels be updated to warn that when used for malaria prophylaxis the drug should be discontinued at the onset of neurologic or psychiatric symptoms. These recent changes to the international labeling serve to imply that psychiatric and neurologic reactions to mefloquine prophylaxis may be an early warning of an impending more serious reaction that may further jeopardize the patient with continued use of the drug. To prevent these more serious effects, these drug labels now warn that mefloquine should be discontinued and that patients seek immediate medical intervention to obtain an alternative antimalarial drug when psychiatric or neurologic symptoms occur. When used correctly for malaria prophylaxis as the updated labeling now directs, it is reasonable to expect that mefloquine will be discontinued, and an alternative drug substituted, in each patient who develops psychiatric or neurologic symptoms. This opinion discusses the implications of this updated labeling for the reporting of adverse reactions and for the continued use of the drug in malaria prophylaxis.
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Affiliation(s)
- Remington L. Nevin
- Department of Environmental Health and EngineeringJohns Hopkins Bloomberg School of Public HealthBaltimoreMaryland
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7
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Bitta MA, Kariuki SM, Mwita C, Gwer S, Mwai L, Newton CRJC. Antimalarial drugs and the prevalence of mental and neurological manifestations: A systematic review and meta-analysis. Wellcome Open Res 2017. [PMID: 28630942 PMCID: PMC5473418 DOI: 10.12688/wellcomeopenres.10658.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Antimalarial drugs affect the central nervous system, but it is difficult to differentiate the effect of these drugs from that of the malaria illness. We conducted a systematic review to determine the association between anti-malarial drugs and mental and neurological impairment in humans. Methods: We systematically searched online databases, including Medline/PubMed, PsychoInfo, and Embase, for articles published up to 14th July 2016. Pooled prevalence, heterogeneity and factors associated with prevalence of mental and neurological manifestations were determined using meta-analytic techniques. Results: Of the 2,349 records identified in the initial search, 51 human studies met the eligibility criteria. The median pooled prevalence range of mental and neurological manifestations associated with antimalarial drugs ranged from 0.7% (dapsone) to 48.3% (minocycline) across all studies, while it ranged from 0.6% (pyrimethamine) to 42.7% (amodiaquine) during treatment of acute malaria, and 0.7% (primaquine/dapsone) to 55.0% (sulfadoxine) during prophylaxis. Pooled prevalence of mental and neurological manifestations across all studies was associated with an increased number of antimalarial drugs (prevalence ratio= 5.51 (95%CI, 1.05-29.04); P=0.045) in a meta-regression analysis. Headaches (15%) and dizziness (14%) were the most common mental and neurological manifestations across all studies. Of individual antimalarial drugs still on the market, mental and neurological manifestations were most common with the use of sulphadoxine (55%) for prophylaxis studies and amodiaquine (42.7%) for acute malaria studies. Mefloquine affected more domains of mental and neurological manifestations than any other antimalarial drug. Conclusions: Antimalarial drugs, particularly those used for prophylaxis, may be associated with mental and neurological manifestations, and the number of antimalarial drugs taken determines the association. Mental and neurological manifestations should be assessed following the use of antimalarial drugs.
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Affiliation(s)
- Mary A Bitta
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Clifford Mwita
- Department of Surgery, Thika Level 5 Hospital, Thika, Kenya.,Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya
| | - Samson Gwer
- Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya.,Department of Medical Physiology, School of Medicine, Kenyatta University, Nairobi, Kenya
| | - Leah Mwai
- Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya
| | - Charles R J C Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
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8
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Bitta MA, Kariuki SM, Mwita C, Gwer S, Mwai L, Newton CRJC. Antimalarial drugs and the prevalence of mental and neurological manifestations: A systematic review and meta-analysis. Wellcome Open Res 2017. [PMID: 28630942 DOI: 10.12688/wellcomeopenres.10658.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Antimalarial drugs affect the central nervous system, but it is difficult to differentiate the effect of these drugs from that of the malaria illness. We conducted a systematic review to determine the association between anti-malarial drugs and mental and neurological impairment in humans. Methods: We systematically searched online databases, including Medline/PubMed, PsychoInfo, and Embase, for articles published up to 14th July 2016. Pooled prevalence, heterogeneity and factors associated with prevalence of mental and neurological manifestations were determined using meta-analytic techniques. Results: Of the 2,349 records identified in the initial search, 51 human studies met the eligibility criteria. The median pooled prevalence range of mental and neurological manifestations associated with antimalarial drugs ranged from 0.7% (dapsone) to 48.3% (minocycline) across all studies, while it ranged from 0.6% (pyrimethamine) to 42.7% (amodiaquine) during treatment of acute malaria, and 0.7% (primaquine/dapsone) to 55.0% (sulfadoxine) during prophylaxis. Pooled prevalence of mental and neurological manifestations across all studies was associated with an increased number of antimalarial drugs (prevalence ratio= 5.51 (95%CI, 1.05-29.04); P=0.045) in a meta-regression analysis. Headaches (15%) and dizziness (14%) were the most common mental and neurological manifestations across all studies. Of individual antimalarial drugs still on the market, mental and neurological manifestations were most common with the use of sulphadoxine (55%) for prophylaxis studies and amodiaquine (42.7%) for acute malaria studies. Mefloquine affected more domains of mental and neurological manifestations than any other antimalarial drug. Conclusions: Antimalarial drugs, particularly those used for prophylaxis, may be associated with mental and neurological manifestations, and the number of antimalarial drugs taken determines the association. Mental and neurological manifestations should be assessed following the use of antimalarial drugs.
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Affiliation(s)
- Mary A Bitta
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Clifford Mwita
- Department of Surgery, Thika Level 5 Hospital, Thika, Kenya.,Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya
| | - Samson Gwer
- Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya.,Department of Medical Physiology, School of Medicine, Kenyatta University, Nairobi, Kenya
| | - Leah Mwai
- Joanna Briggs Institute (JBI) Affiliate Centre for Evidence-Based Healthcare in Kenya, Clinical Research Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya
| | - Charles R J C Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
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9
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Nevin RL, Leoutsakos JM. Identification of a Syndrome Class of Neuropsychiatric Adverse Reactions to Mefloquine from Latent Class Modeling of FDA Adverse Event Reporting System Data. Drugs R D 2017; 17:199-210. [PMID: 28063022 PMCID: PMC5318335 DOI: 10.1007/s40268-016-0167-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Although mefloquine use is known to be associated with a risk of severe neuropsychiatric adverse reactions that are often preceded by prodromal symptoms, specific combinations of neurologic or psychiatric reactions associated with mefloquine use are not well described in the literature. This study sought to identify a distinct neuropsychiatric syndrome class associated with mefloquine use in reports of adverse events. Methods Latent class modeling of US Food and Drug Administration Adverse Event Reporting System (FAERS) data was performed using indicators defined by the Medical Dictionary for Regulatory Activities neurologic and psychiatric high-level group terms, in a study dataset of FAERS reports (n = 5332) of reactions to common antimalarial drugs. Results A distinct neuropsychiatric syndrome class was identified that was strongly and significantly associated with reports of mefloquine use (odds ratio = 3.92, 95% confidence interval 2.91–5.28), defined by a very high probability of symptoms of deliria (82.7%) including confusion and disorientation, and a moderate probability of other severe psychiatric and neurologic symptoms including dementia and amnesia (18.6%) and seizures (18.1%). The syndrome class was also associated with symptoms that are considered prodromal including anxiety, depression, sleep disturbance, and abnormal dreams, and neurological symptoms such as dizziness, vertigo, and paresthesias. Conclusions This study confirms in FAERS reports the existence of a severe mefloquine neuropsychiatric syndrome class associated with common symptoms that may be considered prodromal. Clinical identification of the characteristic symptoms of this syndrome class may aid in improving case finding in pharmacovigilance studies of more serious adverse reactions to the drug.
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Affiliation(s)
- Remington L Nevin
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA.
| | - Jeannie-Marie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Chansky PB, Werth VP. Accidental hydroxychloroquine overdose resulting in neurotoxic vestibulopathy. BMJ Case Rep 2017; 2017:bcr-2016-218786. [PMID: 28404567 DOI: 10.1136/bcr-2016-218786] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hydroxychloroquine is an oral antimalarial medication commonly used off-label for a variety of rheumatological conditions, including systemic lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome and dermatomyositis. We present a case of a 64-year-old woman who presented with acute onset headache, bilateral tinnitus, and left-sided facial numbness and tingling in the setting of accidentally overdosing on hydroxychloroquine. By the next morning, the patient began to experience worsening in the tingling sensation and it eventually spread to her left arm, thigh and distal extremities. The patient also complained of new onset blurring of her peripheral vision and feeling 'off balance.' Despite a complete neurological and ophthalmological work-up with unremarkable imaging and blood work, the patient has had no improvement in her tinnitus, left-sided paresthesias, visual disturbance or ataxia. This is a unique case of hydroxychloroquine overdose resulting in permanent neurotoxic vestibulopathy.
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Affiliation(s)
- Peter B Chansky
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Jain M, Nevin RL, Ahmed I. Mefloquine-associated dizziness, diplopia, and central serous chorioretinopathy: a case report. J Med Case Rep 2016; 10:305. [PMID: 27799060 PMCID: PMC5088661 DOI: 10.1186/s13256-016-1091-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 10/06/2016] [Indexed: 12/02/2022] Open
Abstract
Background Many acute and chronic neurological sequelae from the quinoline derivative antimalarial drug mefloquine, including dizziness and effects on the visual system such as diplopia and blurred vision, may be attributable to focal central nervous system toxicity. Maculopathy has also been reported with use of mefloquine, although the mechanism of this effect has remained unclear. Identification of a common mechanism of toxicity plausibly underlying these visual and non-visual effects may provide broader insights into the acute and chronic neuropsychiatric effects of this and other quinoline antimalarial drugs. Case presentation This case report describes a 30-year-old man of Pakistani descent with sudden onset of dizziness and diplopia following the administration of mefloquine who developed macular changes diagnosed as acute central serous chorioretinopathy by angiography and optical coherence tomography. Similarities between the visual conditions observed in this case and those observed following administration of related quinoline derivative antimalarial drugs including quinine are considered, and plausible mechanisms for the observed drug-induced toxicity are discussed. Conclusions It is proposed that central serous chorioretinopathy be considered a potential ophthalmological sign of mefloquine central nervous system toxicity, and for this effect to potentially indicate susceptibility to other neuropsychiatric effects of mefloquine intoxication. Treating physicians should be aware of the potential for acute and chronic ocular effects resulting from administration of mefloquine and other quinoline antimalarial drugs.
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Affiliation(s)
- Manish Jain
- Department of Ophthalmology, NMC Specialty Hospital, Al Ain, United Arab Emirates
| | - Remington L Nevin
- Department of Environmental Health & Engineering, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA.
| | - Iajaz Ahmed
- Department of Medicine, NMC Specialty Hospital, Al Ain, United Arab Emirates
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Nevin RL, Croft AM. Psychiatric effects of malaria and anti-malarial drugs: historical and modern perspectives. Malar J 2016; 15:332. [PMID: 27335053 PMCID: PMC4918116 DOI: 10.1186/s12936-016-1391-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 06/15/2016] [Indexed: 11/10/2022] Open
Abstract
The modern medical literature implicates malaria, and particularly the potentially fatal form of cerebral malaria, with a risk of neurocognitive impairment. Yet historically, even milder forms of malaria were associated in the literature with a broad range of psychiatric effects, including disorders of personality, mood, memory, attention, thought, and behaviour. In this article, the history of psychiatric effects attributed to malaria and post-malaria syndromes is reviewed, and insights from the historical practice of malariotherapy in contributing to understanding of these effects are considered. This review concludes with a discussion of the potentially confounding role of the adverse effects of anti-malarial drugs, particularly of the quinoline class, in the unique attribution of certain psychiatric effects to malaria, and of the need for a critical reevaluation of the literature in light of emerging evidence of the chronic nature of these adverse drug effects.
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Affiliation(s)
- Remington L. Nevin
- />Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 782, Baltimore, MD 21205 USA
| | - Ashley M. Croft
- />School of Pharmacy and Biomedical Science, University of Portsmouth, James Watson Building (West), Portsmouth, Hants PO1 2FR UK
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Livezey J, Oliver T, Cantilena L. Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine. DRUG SAFETY - CASE REPORTS 2016; 3:7. [PMID: 27747687 PMCID: PMC5005770 DOI: 10.1007/s40800-016-0030-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 32-year-old male developed neuropsychiatric symptoms 2 weeks after starting mefloquine 250 mg/week for malaria prophylaxis. He continued to take the medication for the next 4 months. Initial symptoms included vivid dreams and anxiety, as well as balance problems. These symptoms persisted and progressed over the next 4 years to include vertigo, emotional lability, and poor short-term memory, which have greatly affected his personal and professional life. An extensive evaluation revealed objective evidence supporting a central vestibulopathy. These symptoms have been unresponsive to pharmacologic therapy and psychotherapy. A Naranjo assessment score of 6 was obtained for his initial symptoms, indicating a probable adverse drug reaction to mefloquine given the relationship between the clinical picture and drug exposure.
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Affiliation(s)
- Jeffrey Livezey
- Department of Clinical Pharmacology, Experimental Therapeutics, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA.
| | - Thomas Oliver
- Division of Clinical Pharmacology and Medical Toxicology, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Louis Cantilena
- Division of Clinical Pharmacology and Medical Toxicology, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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Neuropsychiatric Adverse Reactions to Mefloquine: a Systematic Comparison of Prescribing and Patient Safety Guidance in the US, UK, Ireland, Australia, New Zealand, and Canada. Neurol Ther 2016; 5:69-83. [PMID: 27240849 PMCID: PMC4919134 DOI: 10.1007/s40120-016-0045-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 11/28/2022] Open
Abstract
Introduction The antimalarial drug mefloquine (MQ) is associated with neuropsychiatric adverse reactions, some of which may predict the development of more serious effects. Although prescribing guidance in the United States drug label (DL) recommends to discontinue MQ at the onset of neuropsychiatric symptoms, only certain reactions are listed in both the DL and the corresponding patient medication guide with a recommendation to discontinue or to consult a physician should they occur. To identify possible prodromal reactions for which there is complete or partial agreement in prescribing and patient recommendations, a systematic comparison of international drug safety labeling was performed. Methods The full text of each DL and medication guide (or equivalent) from six primarily English-speaking countries was reviewed to identify specific reactions with corresponding recommendations in drug safety labeling. Percentage agreement across the countries in corresponding recommendations was determined by MedDRA® high level group term (HLGT). Results Recommendations were found for reactions in 22 neuropsychiatric HLGTs. Complete or partial international agreement was found for reactions in 11 (50%) HLGTs. Conclusion This analysis suggests opportunities for physicians to improve patient counseling and for international drug regulators to clarify language in MQ safety labeling to reflect national risk–benefit considerations.
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Abstract
INTRODUCTION Antimalarial drugs are the primary weapon to treat parasite infection, save lives, and curtail further transmission. Accumulating data have indicated that at least some antimalarial drugs may contribute to severe neurological and/or psychiatric side effects which further complicates their use and limits the pool of available medications. AREAS COVERED In this review article, we summarize published scientific studies in search of evidence of the neuropsychiatric effects that may be attributed to the commonly used antimalarial drugs administered alone or in combination. Each individual drug was used as a search term in addition to keywords such as neuropsychiatric, adverse events, and neurotoxicity. EXPERT OPINION Accumulating data based on published reports over several decades have suggested that among the major commonly used antimalarial drugs, only mefloquine exhibited clear indications of serious neurological and/or psychiatric side effects. A more systematic approach to assess the neuropsychiatric adverse effects of new or repurposed antimalarial drugs on their safety, tolerability and efficacy phases of clinical studies and in post-marketing surveillance, is needed to ensure that these life-saving tools remain available and can be prescribed with appropriate caution and medical judgment.
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Affiliation(s)
- Bryan Grabias
- a Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases , Center for Biologics Evaluation and Research, Food and Drug Administration , Silver Spring , MD , USA
| | - Sanjai Kumar
- a Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases , Center for Biologics Evaluation and Research, Food and Drug Administration , Silver Spring , MD , USA
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Spring MD, Pichyangkul S, Lon C, Gosi P, Yongvanichit K, Srichairatanakul U, Limsalakpeth A, Chaisatit C, Chann S, Sriwichai S, Auayapon M, Chaorattanakawee S, Dutta S, Prom S, Meng Chour C, Walsh DS, Angov E, Saunders DL. Antibody profiles to plasmodium merozoite surface protein-1 in Cambodian adults during an active surveillance cohort with nested treatment study. Malar J 2016; 15:17. [PMID: 26747132 PMCID: PMC4706704 DOI: 10.1186/s12936-015-1058-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/17/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In addition to evidence for a protective role of antibodies to the malaria blood stage antigen merozoite surface protein 1 (MSP1), MSP1 antibodies are also considered as a marker of past malaria exposure in sero-epidemiological studies. METHODS In order to better assess the potential use of MSP1 serology in malaria chemoprophylaxis trials in endemic areas, an analysis for the prevalence of antibodies to both Plasmodium falciparum and Plasmodium vivax MSP142 in healthy Cambodian adults was conducted at two sites as part of an active, observational cohort evaluating the efficacy of dihydroartemisinin-piperaquine (DP) for uncomplicated malaria (ClinicalTrials.gov identifier NCT01280162). RESULTS Rates of baseline sero-positivity were high (59 and 73% for PfMSP142 and PvMSP142, respectively), and titers higher in those who lived in a higher transmission area, although there was little correlation in titers between the two species. Those volunteers who subsequently went on to develop malaria had higher baseline MSP142 titers than those who did not for both species. Titers to both antigens remained largely stable over the course of the 4-6 month study, except in those infected with P. falciparum who had multiple recurrences. CONCLUSION These findings illuminate the difficulties in using MSP142 serology as either a screening criterion and/or biomarker of exposure in chemoprophylaxis studies. Further work remains to identify useful markers of malarial infection and/or immunity.
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Affiliation(s)
- Michele D Spring
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Sathit Pichyangkul
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Panita Gosi
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Kosol Yongvanichit
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | | | - Amporn Limsalakpeth
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Chaiyaporn Chaisatit
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Soklyda Chann
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Sabaithip Sriwichai
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
| | - Montida Auayapon
- Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Bangkok, Thailand.
| | | | - Sheetij Dutta
- Walter Reed Army Institute of Research, Silver Spring, MD, USA.
| | | | - Char Meng Chour
- National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia.
| | | | - Evelina Angov
- Walter Reed Army Institute of Research, Silver Spring, MD, USA.
| | - David L Saunders
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand.
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17
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McCarthy S. Malaria Prevention, Mefloquine Neurotoxicity, Neuropsychiatric Illness, and Risk-Benefit Analysis in the Australian Defence Force. J Parasitol Res 2015; 2015:287651. [PMID: 26793391 PMCID: PMC4697095 DOI: 10.1155/2015/287651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/13/2015] [Indexed: 11/17/2022] Open
Abstract
The Australian Defence Force (ADF) has used mefloquine for malaria chemoprophylaxis since 1990. Mefloquine has been found to be a plausible cause of a chronic central nervous system toxicity syndrome and a confounding factor in the diagnosis of existing neuropsychiatric illnesses prevalent in the ADF such as posttraumatic stress disorder and traumatic brain injury. Overall health risks appear to have been mitigated by restricting the drug's use; however serious risks were realised when significant numbers of ADF personnel were subjected to clinical trials involving the drug. The full extent of the exposure, health impacts for affected individuals, and consequences for ADF health management including mental health are not yet known, but mefloquine may have caused or aggravated neuropsychiatric illness in large numbers of patients who were subsequently misdiagnosed and mistreated or otherwise failed to receive proper care. Findings in relation to chronic mefloquine neurotoxicity were foreseeable, but this eventuality appears not to have been considered during risk-benefit analyses. Thorough analysis by the ADF would have identified this long-term risk as well as other qualitative risk factors. Historical exposure of ADF personnel to mefloquine neurotoxicity now also necessitates ongoing risk monitoring and management in the overall context of broader health policies.
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Affiliation(s)
- Stuart McCarthy
- Headquarters 2nd Division, Australian Army, Randwick Barracks, Randwick, NSW 2031, Australia
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18
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Holden JM, Slivicki R, Dahl R, Dong X, Dwyer M, Holley W, Knott C. Behavioral effects of mefloquine in tail suspension and light/dark tests. SPRINGERPLUS 2015; 4:702. [PMID: 26609504 PMCID: PMC4648841 DOI: 10.1186/s40064-015-1483-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/29/2015] [Indexed: 11/10/2022]
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19
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Rational Risk-Benefit Decision-Making in the Setting of Military Mefloquine Policy. J Parasitol Res 2015; 2015:260106. [PMID: 26579231 PMCID: PMC4633683 DOI: 10.1155/2015/260106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022] Open
Abstract
Mefloquine is an antimalarial drug that has been commonly used in military settings since its development by the US military in the late 1980s. Owing to the drug's neuropsychiatric contraindications and its high rate of inducing neuropsychiatric symptoms, which are contraindications to the drug's continued use, the routine prescribing of mefloquine in military settings may be problematic. Due to these considerations and to recent concerns of chronic and potentially permanent psychiatric and neurological sequelae arising from drug toxicity, military prescribing of mefloquine has recently decreased. In settings where mefloquine remains available, policies governing prescribing should reflect risk-benefit decision-making informed by the drug's perceived benefits and by consideration both of the risks identified in the drug's labeling and of specific military risks associated with its use. In this review, these risks are identified and recommendations are made for the rational prescribing of the drug in light of current evidence.
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20
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Quinn JC. Complex Membrane Channel Blockade: A Unifying Hypothesis for the Prodromal and Acute Neuropsychiatric Sequelae Resulting from Exposure to the Antimalarial Drug Mefloquine. J Parasitol Res 2015; 2015:368064. [PMID: 26576290 PMCID: PMC4630403 DOI: 10.1155/2015/368064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/28/2015] [Indexed: 12/18/2022] Open
Abstract
The alkaloid toxin quinine and its derivative compounds have been used for many centuries as effective medications for the prevention and treatment of malaria. More recently, synthetic derivatives, such as the quinoline derivative mefloquine (bis(trifluoromethyl)-(2-piperidyl)-4-quinolinemethanol), have been widely used to combat disease caused by chloroquine-resistant strains of the malaria parasite, Plasmodium falciparum. However, the parent compound quinine, as well as its more recent counterparts, suffers from an incidence of adverse neuropsychiatric side effects ranging from mild mood disturbances and anxiety to hallucinations, seizures, and psychosis. This review considers how the pharmacology, cellular neurobiology, and membrane channel kinetics of mefloquine could lead to the significant and sometimes life-threatening neurotoxicity associated with mefloquine exposure. A key role for mefloquine blockade of ATP-sensitive potassium channels and connexins in the substantia nigra is considered as a unifying hypothesis for the pathogenesis of severe neuropsychiatric events after mefloquine exposure in humans.
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Affiliation(s)
- Jane C. Quinn
- Plant and Animal Toxicology Group, School of Animal and Veterinary Sciences, Graham Centre for Agricultural Innovation, Charles Sturt University, Boorooma Street, Wagga Wagga, NSW 2650, Australia
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21
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Maxwell NM, Nevin RL, Stahl S, Block J, Shugarts S, Wu AHB, Dominy S, Solano-Blanco MA, Kappelman-Culver S, Lee-Messer C, Maldonado J, Maxwell AJ. Prolonged neuropsychiatric effects following management of chloroquine intoxication with psychotropic polypharmacy. Clin Case Rep 2015; 3:379-87. [PMID: 26185633 PMCID: PMC4498847 DOI: 10.1002/ccr3.238] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/14/2014] [Accepted: 02/20/2015] [Indexed: 11/06/2022] Open
Abstract
Susceptibility to quinoline antimalarial intoxication may reflect individual genetic and drug-induced variation in neuropharmacokinetics. In this report, we describe a case of chloroquine intoxication that appeared to be prolonged by subsequent use of multiple psychotropic medications. This case highlights important new considerations for the management of quinoline antimalarial intoxication.
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Affiliation(s)
| | | | - Stephen Stahl
- University of California, San Diego San Diego, California
| | - Jerald Block
- Veterans Administration Medical Center Portland, Oregon
| | | | - Alan H B Wu
- University of California, San Francisco San Francisco, California
| | - Stephen Dominy
- University of California, San Francisco San Francisco, California
| | | | | | | | | | - Andrew J Maxwell
- University of California, San Francisco San Francisco, California ; Stanford University Stanford, California
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22
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Schlagenhauf P, Hatz C, Behrens R, Visser L, Funk M, Holzer B, Beck B, Bourquin C, Etter H, Furrer H, Genton B, Landry P, Chappuis F, Loutan L, Stössel U, Jeschko E, Rossanese A, Nothdurft HD. Mefloquine at the crossroads? Implications for malaria chemoprophylaxis in Europe. Travel Med Infect Dis 2015; 13:192-6. [PMID: 25825015 DOI: 10.1016/j.tmaid.2015.03.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 11/17/2022]
Abstract
Since its introduction to the market in 1985, mefloquine has been used for malaria chemoprophylaxis by more than 35 million travellers. In Europe, in 2014, the European Medicines Agency (EMA) issued recommendations on strengthened warnings, prescribing checklists and updates to the product information of mefloquine. Some malaria prevention advisors question the scientific basis for the restrictions and suggest that this cost-effective, anti-malarial drug will be displaced as a first-line anti-malaria medication with the result that vulnerable groups such as VFR and long-term travellers, pregnant travellers and young children are left without a suitable alternative chemoprophylaxis. This commentary looks at the current position of mefloquine prescribing and the rationale of the new EMA recommendations and restrictions. It also describes the new recommendations for malaria prophylaxis that have been adapted by Switzerland, Germany, Austria and Italy where chemoprophylaxis use is restricted to high-risk malaria-endemic areas.
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Affiliation(s)
- Patricia Schlagenhauf
- University of Zürich Centre for Travel Medicine, Institute for Epidemiology, Biostatistics and Prevention, Hirschengraben 84, CH-8001 Zürich, Switzerland.
| | - Christoph Hatz
- University of Zürich Centre for Travel Medicine, Institute for Epidemiology, Biostatistics and Prevention, Hirschengraben 84, CH-8001 Zürich, Switzerland; Swiss Tropical and Public Health Institute, PO Box, CH-4002 Basel, Switzerland
| | - Ron Behrens
- Hospital for Tropical Diseases Mortimer Market, & London School of Hygiene and Tropical Medicine, London, UK
| | - Leo Visser
- Leiden University Medical Center, Department of Infectious Diseases, C5P-46, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Maia Funk
- University of Zürich Centre for Travel Medicine, Institute for Epidemiology, Biostatistics and Prevention, Hirschengraben 84, CH-8001 Zürich, Switzerland
| | - Benedikt Holzer
- Medi24, Telemedicine Services, Allianz Global Assistance, Bolligenstrasse 54, CH-3006 Berne, Switzerland
| | - Bernhard Beck
- Swiss Tropical and Public Health Institute, PO Box, CH-4002 Basel, Switzerland
| | | | | | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, CH 3010 Bern, Switzerland
| | - Blaise Genton
- PMU
- Policlinique Médicale Universitaire, Lausanne, Switzerland
| | - Pierre Landry
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, 6 rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Francois Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, 6 rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Louis Loutan
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, 6 rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Ulrich Stössel
- Swiss Int. Air Lines Ltd., Medical Services, 8058 Zurich Airport, Switzerland
| | | | - Andrea Rossanese
- Centre for Tropical Diseases, "Sacro Cuore-Don Calabria" Hospital, Negrar, Verona, Italy
| | - Hans Dieter Nothdurft
- University Hospital of Munich, Dep. of Infectious Diseases and Tropical Medicine, Leopoldstrasse 5, 80802 Munich, Germany
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23
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Nevin RL. Organic depersonalization as a chronic sequela of mefloquine intoxication. PSYCHOSOMATICS 2014; 56:103. [PMID: 25619679 DOI: 10.1016/j.psym.2014.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 08/24/2014] [Accepted: 08/25/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Remington L Nevin
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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24
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Ramos-Martín V, González-Martínez C, Mackenzie I, Schmutzhard J, Pace C, Lalloo DG, Terlouw DJ. Neuroauditory toxicity of artemisinin combination therapies-have safety concerns been addressed? Am J Trop Med Hyg 2014; 91:62-73. [PMID: 24865683 PMCID: PMC4080570 DOI: 10.4269/ajtmh.13-0702] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Although artemisinin-based combination therapies (ACTs) are widely viewed as safe drugs with a wide therapeutic dose range, concerns about neuroauditory safety of artemisinins arose during their development. A decade ago, reviews of human data suggested a potential neuro-ototoxic effect, but the validity of these findings was questioned. With 5–10 years of programmatic use, emerging artemisinin-tolerant falciparum malaria in southeast Asia, and the first calls to consider an increased dose of artemisinins, we review neuroauditory safety data on ACTs to treat uncomplicated falciparum malaria. Fifteen studies reported a neurological or auditory assessment. The large heterogeneity of neuro-ototoxic end points and assessment methodologies and the descriptive nature of assessments hampered a formal meta-analysis and definitive conclusions, but they highlight the persistent lack of data from young children. This subgroup is potentially most vulnerable to any neuroauditory toxicity because of their development stage, increased malaria susceptibility, and repeated ACT exposure in settings lacking robust safety monitoring.
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Affiliation(s)
| | | | | | | | | | | | - Dianne J. Terlouw
- *Address correspondence to Dianne J. Terlouw, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom. E-mail:
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25
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Nevin RL. Idiosyncratic quinoline central nervous system toxicity: Historical insights into the chronic neurological sequelae of mefloquine. INTERNATIONAL JOURNAL FOR PARASITOLOGY-DRUGS AND DRUG RESISTANCE 2014; 4:118-25. [PMID: 25057461 PMCID: PMC4095041 DOI: 10.1016/j.ijpddr.2014.03.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/17/2014] [Accepted: 03/19/2014] [Indexed: 12/04/2022]
Abstract
Regulators now warn adverse neurological effects from mefloquine may be irreversible. Many neurological effects resemble those of a common quinoline CNS toxidrome. The quinoline toxidrome is associated with a risk of CNS neuronal degeneration. CNS neuronal degeneration may underlie some neurological effects from mefloquine.
Mefloquine is a quinoline derivative antimalarial which demonstrates promise for the treatment of schistosomiasis. Traditionally employed in prophylaxis and treatment of chloroquine-resistant Plasmodium falciparum malaria, recent changes to the approved European and U.S. product labeling for mefloquine now warn of a risk of permanent and irreversible neurological sequelae including vertigo, loss of balance and symptoms of polyneuropathy. The newly described permanent nature of certain of these neurological effects challenges the conventional belief that they are due merely to the long half-life of mefloquine and its continued presence in the body, and raises new considerations for the rational use of the drug against parasitic disease. In this opinion, it is proposed that many of the reported lasting adverse neurological effects of mefloquine are consistent with the chronic sequelae of a well characterized but idiosyncratic central nervous system (CNS) toxicity syndrome (or toxidrome) common to certain historical antimalarial and antiparasitic quinolines and associated with a risk of permanent neuronal degeneration within specific CNS regions including the brainstem. Issues in the development and licensing of mefloquine are then considered in the context of historical awareness of the idiosyncratic CNS toxicity of related quinoline drugs. It is anticipated that the information presented in this opinion will aid in the future clinical recognition of the mefloquine toxidrome and its chronic sequelae, and in informing improved regulatory evaluation of mefloquine and related quinoline drugs as they are explored for expanded antiparasitic use and for other indications.
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Affiliation(s)
- Remington L Nevin
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 782, Baltimore, MD 21205, United States
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26
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Nevin RL. Falling rates of malaria among U.S. military service members in Afghanistan substantiate findings of high compliance with daily chemoprophylaxis. Am J Trop Med Hyg 2012; 87:957-958. [PMID: 23136173 PMCID: PMC3516276 DOI: 10.4269/ajtmh.2012.12-0277a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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27
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Nevin RL. Mass administration of the antimalarial drug mefloquine to Guantánamo detainees: a critical analysis. Trop Med Int Health 2012; 17:1281-8. [PMID: 22882560 DOI: 10.1111/j.1365-3156.2012.03063.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recently, evidence has emerged from an unusual form of mass drug administration practised among detainees held at US Naval Station Guantánamo Bay, Cuba ('Guantánamo'), ostensibly as a public health measure. Mefloquine, an antimalarial drug originally developed by the US military, whose use is associated with a range of severe neuropsychiatric adverse effects, was administered at treatment doses to detainees immediately upon their arrival at Guantánamo, prior to laboratory testing for malaria and irrespective of symptoms of disease. In this analysis, the history of mefloquine's development is reviewed and the indications for its administration at treatment doses are discussed. The stated rationale for the use of mefloquine among Guantánamo detainees is then evaluated in the context of accepted forms of population-based malaria control. It is concluded that there was no plausible public health indication for the use of mefloquine at Guantánamo and that based on prevailing standards of care, the clinical indications for its use are decidedly unclear. This analysis suggests the troubling possibility that the use of mefloquine at Guantánamo may have been motivated in part by knowledge of the drug's adverse effects, and points to a critical need for further investigation to resolve unanswered questions regarding the drug's potentially inappropriate use.
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Affiliation(s)
- Remington L Nevin
- Department of Preventive Medicine, Bayne-Jones Army Community Hospital, Ft. Polk, LA, USA
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