Use mefloquine for UK troops only as “last resort,” MPs tell Ministry of DefenceBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2946 (Published 24 May 2016) Cite this as: BMJ 2016;353:i2946
British military personnel should be given the antimalarial drug mefloquine (which is marketed in the United Kingdom as Lariam) only as a “last resort,” MPs have concluded.1
In a report into the use of the drug among the armed forces, the House of Commons Defence Committee accused the Ministry of Defence of displaying a “lamentable weakness in [its] duty of care towards service personnel” and of ignoring the “stringent conditions” for safe prescribing set out by the drug’s manufacturer, Roche.
“We see no reason to disbelieve the very strong anecdotal evidence that such conditions have been ignored in dispensing it to large numbers of troops about to be deployed. Indeed, it is hard to see how they could ever be met except when the numbers to be individually assessed are few and far between,” said the report.
“It is our firm conclusion that there is neither the need nor any justification for continuing to issue this medication to service personnel unless they can be individually assessed, in accordance with the manufacturer’s requirements,” it said.
The use of mefloquine has been a persistent focus of concern since the 1990s because of the relatively high risk of neuropsychiatric side effects. The report said that mefloquine was prescribed to more than 17 300 military personnel at least once between 1 April 2007 and 31 March 2015. Over the same period 104 000 military personnel were prescribed a different antimalarial.
Last year the Defence Committee wrote to the defence secretary, Michael Fallon, requesting an update on the government’s plans on prescribing the drug after reports in the media that 14% of service personnel who took the drug in 2014 (263 of 1892) had sought medical treatment for side effects.2
In the absence of a “convincing” response the committee set up its own inquiry.
The evidence it received highlighted the specific risks that the drug’s side effects can place on military personnel and the belief that the military environment has the potential to exacerbate them.
The MPs’ report accepts that there may only be a very small number of occasions when prescription of the drug is necessary but nevertheless insists that “the MoD should designate Lariam as a ‘drug of last resort.’” And it should then be prescribed only to those personnel who are unable to take any of the other available alternatives; only after an individual face to face risk assessment; and only after the individual has been made aware of other suitable alternatives, it says.
The report also recommends that the defence ministry establish a widely publicised single point of contact for all current and former service personnel who may have concerns about having taken mefloquine and that it talk to the Department of Health on how best to advise GPs of potential risks to veterans who may have taken mefloquine in the past.
Ashley Croft, a military expert and consultant in public health, who submitted evidence to the inquiry, told The BMJ that the defence committee’s intervention was “extraordinary.” The defence ministry should be “thoroughly ashamed” of itself for having consistently refused to act on mounting concerns about the drug’s side effects, he said.
“Their [the ministry’s] trump card has always been that they followed the advice of the Advisory Committee on Malaria Prevention, but this doesn’t provide specific recommendations for the military,” he explained. Vulnerable military personnel who had no option but to take the treatment that they were given “deserved better,” he insisted.
A spokesperson for Public Health England, within which the advisory committee sits, said that the guidance was updated annually, or sooner if required. “The guidance is designed for medical professionals and other travel medicine advisers based in the UK, and [the committee] does not provide specific advice to any specific occupational groups, including the military,” she confirmed.