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The Army has dropped Lariam the drug linked to side effects including suicidal tendencies, anxiety, aggression and paranoia as its preferred protection against malaria because doctors had inadvertently prescribed it to people who should not take it.
Lariam, the brand name for mefloquine, should not be given to anyone with symptoms of a brain injury, depression or anxiety disorder, which describes many troops who have deployed to Iraq or Afghanistan.
The Army's new choice for anti-malarial protection is doxycycline, a generic antibiotic.
"In areas where doxycycline and mefloquine are equally efficacious in preventing malaria, doxycycline is the drug of choice," Army Surgeon General Lt. Gen. Eric Schoomaker said in a memo dated Feb. 2.
Schoomaker said mefloquine should be given only to troops who can't take doxycycline, and that it is "critically important" that mefloquine not be given to anyone with mental health issues or a recent history of traumatic brain injury.
Col. Scott Stanek of the Army Surgeon General's preventive medicine directorate said the policy change recognizes the concerns about inadvertent prescription of mefloquine to soldiers who should not take it.
The change also "emphasizes the screening health care providers should perform to identify these contraindications before prescribing mefloquine," Stanek said. "Mefloquine will still be available for individuals who have contraindications to doxycycline but do not have contraindications to mefloquine."
The services or a combatant command surgeon usually determines which drug to use based on the malaria threat in each area. In many cases, that puts the decision in the hands of the Army.
Navy officials said sailors and Marines follow those guidelines for malaria, which for Iraq means no malaria prophylactic because the threat there is not significant enough to need it.
In Afghanistan, the policy since 2004 puts doxycycline above mefloquine. In the Horn of Africa, Army directives have preferred mefloquine over doxycycline, but that should change under Schoomaker's memo.
The Air Force also will continue to use mefloquine in some cases, but not as a "blanket prescription" for an entire unit, said Betty-Anne Mauger, spokeswoman for the Air Force Surgeon General.
She said pilots may not use it, and that doctors must review an airman's medical records and counsel him about possible side effects before prescribing it.
In the past, the military has used mefloquine because troops have to take it only once a week, while doxycycline must be taken daily. And in some areas, the malaria parasite has become resistant to doxycycline.
But critics have long said the military exposed service members to an unacceptable risk by giving them a drug that could cause psychotic episodes. As long ago as 1993, Sen. Dianne Feinstein, D-Calif., asked the Pentagon to look at other options after media reports cited possible links between Lariam and suicides and other erratic behavior.
Jeanne Lese, co-director of Lariam Action USA, has petitioned the military as well as the Peace Corps for years to stop using the medication.
"We've heard story after story," she said. "The risk ... is just unacceptable. Why would you take this when you have other alternatives that are safer?"
Mefloquine was approved in 1989 by the Food and Drug Administration only to prevent malaria. Doxycycline has been used as an antibiotic for decades, with the worst side effect being photosensitive skin.
Mefloquine has been found to cause side effects in as many as 25 percent of people who take it, including vomiting, convulsions, psychosis, nightmares, dizziness, confusion, insomnia, unusual dreams, lightheadedness, vertigo, visual disturbances, ringing in the ears, rash and irritability.
It also can cause anxiety, paranoia, depression, agitation, panic attacks, hallucinations, mood changes, aggression and psychotic behavior, according to the Deployment Health and Readiness Library.
A 2004 study by the Walter Reed Institute of Research said mefloquine produces severe seizures and hallucinations and hospitalizations in one out of 10,000 people who take it, and dizziness, headache, insomnia and vivid dreams in up to 25 percent of patients. The study also found that the drug crosses the blood-brain barrier and accumulates in the central nervous system.
A 2006 study out of Walter Reed found that rats given a single dose suffered impairment of motor function and degeneration of brain stem nuclei, as well as activity that suggested sleep disorders. The data also suggested the drug could lead to permanent damage to the central nervous system.