Malarone vs. Doxycycline (Doc V?)

[beche de mer]

Doxycycline is said to have a cut off age of 8 years according to the literature. I am wondering how clearly defined this cutoff point is? For example is my 10 yo absolutely safe from any adverse dental effects? She is realatively small for her age and her second teeth are not all through yet. On the other end of the scale my 7yo will actually be 71/2 by the time we go. Does this mean that she is not safe to take doxycycline, but will be 100% safe six months later when she turns 8?

Neither of my children have taken medication in tablet form, any medication they have had has been in liquid form. So the other consideration is what form the medication takes. Are any of the possible antimalarials available in liquid form? BD

If medications of the tetracycline group (which includes doxycycline) are taken during the period in which the developing teeth are becoming calcified, discolouration can occur. Calcification of the primary dentition (baby teeth) occurs during foetal development, so if tetracyclines are taken during pregnancy, staining of primary dentition may occur.

Calcification of the secondary or adult dentition takes place during the first few years of life. To generalise a bit, the incisors and canines at the front are calcified first (3-12 months), followed by premolars and molars. Calcification of the rear-most molars may not be complete until the age of about 10 years. If tetracyclines are taken during this period, discoloration may occur.

To answer your question: It is highly unlikely that your 10 year old would suffer any adverse effect (in terms of discolouration) from doxycycline. Your 7.5 year old could suffer discolouration of the molars at the back of the mouth which, from a cosmetic point of view, would probably not be significant.

So you'd probably be OK giving the younger one doxycycline, but that would be your decision. Yes, the figures are approximate. There is always individual variation. But your 10 year old should be well past the critical stage by now.

There are no pediatric formulations of doxycycline or Lariam. Most parents seem to manage OK by crushing up the tablet (or fragment thereof) and mixing it with ice-cream or chocolate syrup.

Have a great trip. Bokissa is great and the Coolidge is an endless source of pleasure. There are also some very good dives to be had around Port Vila if you have the time.

 

[reubencahn]

Recently Malarone has become available to us, but at the cost of A$12 per tablet, the cost is frequently prohibitive. (And there are certain definite contra-indications for kids.)

I am travelling to PNG this summer with my son (he will be 12 then) and he will be diving, so Lariam seems out of the question. Doxycycline also seems problematic for the reasons DocVikingo mentioned. (Also, I am allergic to tetracycline.) I had assumed Malarone would be the answer, but perhaps not. Could you elaborate on the contraindications for kids?

Also, could anyone comment on how to find the best travel clinic. I am in the Ft. Lauderdale/Miami area, so there are many. If anyone has a particular recommendation, I would love to hear it.

 

[Laurence Stein DDS]

Hi DocVikingo and All,

Geez, I never thought that I would be called upon in a discussion of antimalarial drugs.

BDM gave a good discription of the ages at risk. That being said, and in a legal climate that allows almost no errors, and if I don't see the second permanent molars in the mouth, I'm going to be reluctant to give my OK based on published recommendations. In fact, until the wisdom teeth (3rd molars) are present in the mouth, you might cause discoloration to those teeth.

The tetracycline is actually deposited into the enamel matrix. There may be grey, green, orange banding in the enamel of the teeth when they erupt. For most, this is a cosmetic problem. In fact, nearly every patient that I have seen with this problem has absolutely no decay and will be very resistant to decay. If this medication was given for periodic infections that involved high fevers, there may also be hypocalcifications in the enamel. These are potential "soft spots" and are a little more likely to decay.

Calcification of the crowns of the permanent start approximately 6 years before their eruption. The calcification starts at the cusp tips of the crowns and proceeds toward the root tips. About 1/3 of the tooth's length is covered in enamel.

I just saw a patient who is 20 years old and her wisdom teeth are just beginning to get ready to erupt. In fact, the upper teeth are barely formed. In this patient, the 8 year cut off would have resulted in staining of the 3rd molars and if she was similarly late with her 2nd molars, they too may have been involved. It wouldn't have made much difference to me but it might upset the patient or parents in the event there is actually enough room for the wisdom teeth to come in.

In answer to Bluedevil's, "Is my 10 yo absolutely safe from any adverse dental effects?" The short answer is POSSIBLY not--especially the wisdom teeth--even though they will most likely be extracted because of a lack of room. Also, be aware that "adverse dental effects" is almost always a cosmetic problem rather than a functional or other health problem.

Taking x-rays of the unerupted teeth would help. If the crowns are obviously formed then the medication will be ok. The chronologic age and the dental age may be significantly different. Without a radiograph to acertain the development of the permanent teeth, a published recommended age limit can very likely be inappropriate. In addition, special permission may be needed to provide informed consent during the formation and eruption of the wisdom teeth.

My best advice...get radiographs of at least the second (12 year) molars and informed consent.

Regards,

Laurence Stein, DDS
:doctor:

 

[peterjmaerz]

Well, this has blossomed into a very interesting tutorial. I've one more question as regards Doxycycline... I've been prone to ear infections in the past and, while my ProEar mask seems to have ameliorated the threat, I'm curious as to whether choosing Doxycycline as my anti-malarial would also serve to protect me from ear infections?

Thanks,

Best,

 

[beche de mer]

I am travelling to PNG this summer with my son (he will be 12 then) and he will be diving, so Lariam seems out of the question. Doxycycline also seems problematic for the reasons DocVikingo mentioned. (Also, I am allergic to tetracycline.) I had assumed Malarone would be the answer, but perhaps not. Could you elaborate on the contraindications for kids?

A quick review of the product information for Malarone reveals that there are, in fact, very few contraindications for kids. The main one is kidney failure. (For some reason I had in my mind that a history of fits during childhood or infancy was also a contra-indication, but that is not the case.)

The product information contained this caution:
"There have been no studies to investigate the effect of atovaquone and proguanil hydrochloride on driving performance or the ability to operate machinery. Detrimental effect on such activities is not predicted from the pharmacology of the component drugs".

So, from a knowledge of the pharmacology of the ingredients of Malarone (atovaquone and proguanil) there is no reason to suppose that it would be a problem with diving - but there is insufficient data on atovaquone to be certain. (Proguanil has been around for years and is known to be OK.)

Malarone would seem to be a good choice for you and your son.

You might find this site helpful:

http://www.cdc.gov/travel/mal_kids_pub.htm

I'd be interested to know the cost of Malarone in the USA.

 

[beche de mer]

Well, this has blossomed into a very interesting tutorial. I've one more question as regards Doxycycline... I've been prone to ear infections in the past and, while my ProEar mask seems to have ameliorated the threat, I'm curious as to whether choosing Doxycycline as my anti-malarial would also serve to protect me from ear infections?

As usual, no simple answer. There are various types of ear infections. Simple "tropical ear" is a fungal infection in the external ear canal. Doxycycline will have no effect on this.

Sometimes tropical ear is complicated by a bacterial infection which involves the skin and subcutaneous tissues of the ear canal. When this happens the ear is usually extremely tender. Being a bacterial infection, doxycycline might help, if the particular bacterial culprit is sensitive to doxycycline. (Though few doctors would prescribe doxycycline as the antibiotic of first choice for the treatment of this condition.)

And then there is otitis media, or middle ear infection - another bacterial infection which may or may not be sensitive to doxycycline.

So the answer to your question is maybe - maybe not.

One possible of benefit of doxycycline, particularly if travelling to developing countries, is some degree of protection against gastro-intestinal infections - Delhi belly, Bali belly, Montezuma's revenge, etc. Once upon a time doxycycline was the antibiotic of choice for treating these infections, though there is now a high degree resistance among the causitive organisms.

 

[reubencahn]

Malarone would seem to be a good choice for you and your son.

You might find this site helpful:

http://www.cdc.gov/travel/mal_kids_pub.htm

I'd be interested to know the cost of Malarone in the USA.

Thanks for the information and the site. It will be a while before I'm getting prescriptions filled. But when I do, I'll let you know the cost.

Peter, have you gone to a travel clinic or to your own doctor?

 

[peterjmaerz]

Thanks so very much, Docs! Really appreciate your time on this... Reuben, scheduled my appointment with my GP 6 weeks out from my trip. He, of course, is familiar with my medical history. I figure either he'll agree with my choice of prophylaxis or he'll want a specialist's opinion, in which case he'll send me to someone in his network. Ultimately, I feel certain I can "get my way" and stay within my insurance network.

Best,

 

[peterjmaerz]

BDM: Here's a quote from Healthlink website:

"The cost of Malarone is more expensive than other commonly used medications for malaria prophylaxis. Doxycycline costs pennies per day. Lariam (mefloquine) and Malarone are considerably more expensive; coverage for a two week trip using Malarone daily or Larium weekly may cost between $75 and $100. Malarone becomes more expensive than Larium after two weeks because it requires a daily pill whereas Larium is taken weekly. The price per pill decreases as more pills are purchased and pharmacies have considerable variance in pricing."

 

[beche de mer]

BDM: "The cost of Malarone is more expensive than other commonly used medications for malaria prophylaxis. Doxycycline costs pennies per day. Lariam (mefloquine) and Malarone are considerably more expensive; coverage for a two week trip using Malarone daily or Larium weekly may cost between $75 and $100. Malarone becomes more expensive than Larium after two weeks because it requires a daily pill whereas Larium is taken weekly. The price per pill decreases as more pills are purchased and pharmacies have considerable variance in pricing."

Thanks for that PeterJ. It seems Malarone is rather less expensive in the US than here in Australia. The cost of Malarone for a 2 week trip (22 tablets) would cost us about A$240. (Approx US$190.)

Lariam for 2 weeks, on the other hand, might be a bit cheaper here. A two week trip requires 8 tablets. Less than A$60. (And doxy ~A$22)