'A horror movie in a pill': Make mefloquine last resort for Alberta travellers, critics say

An antimalarial drug commonly prescribed in Alberta is facing growing calls from critics who want it downgraded as a drug of “last resort” for travellers.

'We haven’t seen the safety concerns in the individuals that we’ve prescribed it for'

Dr. Remington Nevin is concerned Alberta prescribers are not fully taking into account the level of risk associated with melfloquine outlined in Health Canada's updated drug description. (Provided)

An antimalarial drug commonly prescribed in Alberta is facing growing calls from critics who want it downgraded as a drug of "last resort" for travellers.

"I am concerned Alberta prescribers are not fully taking into consideration the very significant level of risk acknowledged by the latest product monograph," said Dr. Remington Nevin, a former U.S. Army major and leading expert on the neuropsychiatric side effects of mefloquine.

"The reason Canadian travellers have been placed at risk for the last few years is that … the Canadian government is still in denial about the drug's true dangers."

In August Health Canada revised the drug's prescribing information. The updated label warns that those experiencing side-effects such as anxiety, paranoia, hallucinations, thoughts of suicide and psychotic behaviour must stop using the drug. Side-effects can persist for years or become permanent in some people, it adds.

The Canadian government is still in denial about the drug's true dangers- Dr. Remington Nevin

But Nevin said the updated information was not sufficiently publicized. Canada is "stuck in a culture of denial" because the government fears being held accountable for the events connected to Somalia and mefloquine two and a half decades ago, he said.

In the early 1990s, 900 members of the Canadian Airborne Regiment on a peacekeeping mission in Somalia were among the first Canadians to take mefloquine.

Camel spiders

Former soldier John Dowe said the drug left him with insomnia and nightmares, but for others in his contingent it was far worse.

Dowe recalled how Cpl. Clayton Matchee "wigged out," beating imaginary camel spiders in the bunker where he held a bruised Somali prisoner.
Canadian veteran John Dowe experienced nightmares, insomnia and other side-effects after taking mefloquine in Somalia in 1993.

When Dowe returned an hour later, Somali teen Shidane Arone's lifeless body was sprawled on the ground as soldiers tried to revive him. Matchee, who was charged in the murder of the teen, was found unfit to stand trial after an apparent suicide attempt, which the family questions, caused brain damage. The charges were withdrawn.

Twenty-five years later, the military still considers mefloquine a viable option for soldiers — something Dowe is lobbying to change. The Canadian Department of National Defence says soldiers are free to take another antimalarial medication, however.

"The weight of evidence supports the opinion that the use of Mefloquine by military personnel is not associated with an increased risk of adverse effects associated harm compared to alternatives," the department said in an email to CBC.

'Placing civilians at great risk'

Dowe, who has co-founded the International Mefloquine Veterans Alliance, said mefloquine should only be used by travellers as a last resort.

"It's placing civilians at great risk because the literature is not up to speed as it should be, and as it is internationally," said Dowe, who is also leading the push for an inquiry into the consequences mefloquine had on soldiers during the Somalia mission.
Canadian veteran John Dowe said mefloquine should be prescribed as a last resort for Alberta travelers. (John Dowe)

"In doing the research I understood the great gap that Canada is in right now in relation to our allies in the other countries in their proactiveness of removing mefloquine."

In 2013, the US Food and Drug Administration strengthened its warning on mefloquine's label "due to risk of serious psychiatric and nerve side effects". Afterwards, the U.S. Special Forces stopped using the drug altogether.

"Alberta needs a much more prominent and clear statement and directive from Health Canada," said Dowe.

Mefloquine, also known by the brand name Lariam, is one of several antimalarial options that includes doxycycline and Malerone (a combination of atovaquone and proguanil).

Roche, the manufacturer of Lariam, declined comment about the risk allegations. But the drug is still being defended by Alberta health authorities.

'A reasonable choice'

"Mefloquine is actually a reasonable choice and our experience with using mefloquine has been good," said Judy MacDonald, medical officer of health with Alberta Health Services. "From our experience we haven't seen the safety concerns in the individuals that we've prescribed it for."

Prescribing practices did not change after August's update to the label, said MacDonald.  She said it wasn't necessary because clients were already being warned about risks and precautions.

MacDonald said mefloquine is the only option for new babies, children or pregnant women, if other risk factors aren't present.
Dr. Judy MacDonald said mefloquine is the only option for some clients. (Stephanie Wiebe/CBC)

It is not a good option for anyone with anxiety, active depression or psychosis, which patients are asked about during a "careful risk assessment," she said.

Nurses go over the side effects of mefloquine and those who experience problems are instructed to call health officials. But MacDonald said those kind of calls are "very rare."

Nevin disagrees with MacDonald about the risks.

"It is literally a horror movie in a pill," said Nevin, estimating about a third of patients experience side effects which require them to stop taking the drug. 

"And any physician who would recommend this drug to an infant or a preverbal child does not understand the product" label information, he argued.

'Irresponsible and cruel'

Nevin said the updated drug information clarifies that reactions can be permanent. And it advises prescribers to tell patients to stop taking the drug as soon as they experience symptoms such as vivid dreams, insomnia or mild mood changes -- which might be the only warning signs to avoid permanent brain injury.

"I think it is terribly irresponsible and cruel to prescribe this drug to an infant or a preverbal child who may experience horrific side effects and have no way to communicate that to their parents," said Nevin.

The common assumption the drug is safe for people without mental illness "is absolutely not the case," he added.

The benefits of mefloquine outweigh its risks when it is used as directed- Health Canada

Bev Skwernuik said she was convinced she had special powers, bestowed on her by Jesus, after an Edmonton travel clinic prescribed mefloquine in 1998.

Nearly two decades later, Skwernuik, an optometrist who lives in Comox, B.C., is surprised the drug is still widely prescribed and also believes it should be a last resort.

"Mefloquine -- it's Russian roulette," she said. "You don't know if you're going to be the one who's going to have a side effect and sometimes it's hard to feel or see it until it's too late."
Bev Skwernuik said she experienced delusions, hallucinations and paranoia after taking mefloquine prescribed by an Edmonton travel clinic.

In a statement, Health Canada said prescribing information was updated to better emphasize mefloquine's known risks and that certain side-effects can persist for months or years afterwards "and may be permanent in some patients."

The update took into account prescribing information from the U.S. Food and Drug Administration, European regulators  and risks of malaria, which killed an estimated half a million people in 2015, according to the statement.

"The benefits of mefloquine outweigh its risks when it is used as directed," the Health Canada statement added.

@andreahuncar     andrea.huncar@cbc.ca