I’ve just finished reading several years’ worth of your responses to questions and I’m very impressed. Thank you for being surely one of the best sources on the web. My question pertains to the shelf life of Malarone tablets. My husband and I have been in Madagascar for three weeks now and will stay for another two and a half months. I am very preventive-oriented (long sleeves, pants and socks, mosquito tent at night) as mosquitos love me. I am not however taking a chemical prophylactic. I have brought with me 11 Malarone tablets (GlaxoKlineSmith) bought on prescription in France some years ago and whose expiration date is… 2010. If I do come down with the symptoms (likely falciparum) and test positive, would I not be better off taking these perimated pills than eventually buying counterfeit ones here, if you can get them, as I read on the internet that drug companies are very conservative re shelf life (the pills are in their original plastic/aluminum airtight wrappings)? I say I am preventive-oriented, though I admit that travelling with old Malarone (and not the 12 recommended but only 11) is not too wise.
Thanks so much for your question, and you certainly have done your research! I agree, often the expiry date of medications seems to be overly conservative, but unfortunately without testing the chemical properties of the tablets, you cannot know for sure whether the compounds in the drugs have begun to break down.
I understand your predicament that slightly weaker drugs might be better than counterfeit ones, but ultimately, both might not be completely effective and I would be very concerned about the possible contribution to drug resistance, if you try to treat malaria with a drug which is not fully operational. This is the same effect as taking only 11 out of the required 12 tablets for treatment; it’s like not completing a full course of antibiotics, and can assist the malaria parasite in developing drug resistance.
In your case, I have a couple of recommendations: First of all, you are unlikely to be able to find reliable Malarone, but doxycycline should be available and given how cheap it is as a generic, unlikely to be counterfeit. Given you will be in Madagascar for a reasonably long period of time, you probably should start chemical prophylaxis, and doxycycline could be a good option. The usual dose for prophylaxis is 100mg, taken orally, once a day. You will need to continue taking it every day for four weeks after you leave the malarial area. Most people tolerate doxycycline very well, but it can cause minor side effects such as stomach ache and sensitivity to the sun. You should also make sure to take it 2-3 hours before consuming any dairy products or other items containing calcium or magnesium (antacid tablets, etc), as doxycycline binds to calcium and magnesium, preventing it from being fully absorbed by the body.
Secondly, I would also investigate local pharmacies and clinics and find out which ones stock artemisinin-based combination therapies, such as Coartem, ASAQ, Pyramax or Duo-Cotecxin. Look for artemisinin-derivatives in the list of ingredients such as artesunate, dihydroartemisinin and artemether, together with a combination compound (having a second active ingredient is very important in terms of preventing development of drug resistance) such as lumefantrine, mefloquine, piperaquine and amodiaquine.
It is difficult to identify counterfeit drugs, but look for original packaging (including aluminum casings for the pills), manufacturer’s stamps and an expiry date (obviously you want to make sure the drugs have not expired!). Once you have sourced a suitable pharmacy, if you or your husband comes down with malaria (as you rightly say, once you have been positively tested for falciparum! I’m so happy you are aware of the importance of diagnosis), then you will have a sense of a pharmacy to turn to when you need treatment, though hopefully, if you start taking doxycycline, you will be completely protected!