Malarone and difficulty equalising middle ear pressure?

[MrsBBC]

The purpose of this post is to find out if anybody else has suffered the inability to equalise their middle ear when flying or diving, in the first few days of taking the antimalarial; Malarone

And to suggest that it may be an undocumented side effect.

I therefore apologise if the following documentation of my experience is long winded.

I started taking Malarone 2 days before my flights to Gambia.
No noticeable side effects before flying.
No noticeable side effects during Flight 1; London to Brussels

During Flight 2; Brussels to... tarmac somewhere before taking off again for Gambia I realise that my hearing is very very very muffled. I had not fallen asleep, I guess it just crept up on me. I ask my mate if he has noticed any discernable difference in cabin pressure or had to equalise his ears, he says no.
I loudly ask the people around me the same question and they all stare at me as if I'm mental and then promptly ignore me. Fair enough I was probably being loud and obnoxious on a plane full of people who don't speak English.
The ear situation does not improve.

Upon landing it gets worse, and turns from muffled/cotton wool sound to nagging but tolerable pain.
During take off and ascent the bearable pain becomes unbearable and I sit with my head between my hands with uncontrollable tears streaming down my face for the entire flight (lame), and am unable to equalise no matter how hard I try... I try pretty damn hard.

Upon landing I am very disorientated and confused, last to get through customs because I'm completely 'out of it', and have to pull my luggage off someone else's trolley outside the airport (first few minutes experience in Gambia).
I down a 1.5l water, 2 ibuprofen, 2 paracetamol and fall asleep.

I spend only the one night in Gambia before joining the ship I am to be working on at considerable distance offshore

Side effects continue for 3-4 days including:

• Permanent nausea
• Permanent headache
• Seasickness (which I do not normally suffer from, but its mostly nausea, with seasickness)
• Inability to drink even the smallest amount of water without vomiting -Subsequent dehydration, (exacerbating the headache, and ineffectiveness of the Malarone)
• Confusion/Disorientation (but not as bad as the day I landed)
• Detachment, feeling of 'not being present'
• Lack of appetite (and more vomiting anyway)

Leading to lack of focus and difficulty doing my job

So I opt to miss a day's Malarone and see what happens.
What happens is ALL of the above stop
So I stop taking Malarone
*yes it only takes one mosquito, and yes I did suffer one mosquito bite during the first few days on the ship; there are none left aboard any more. But I could not function well enough to do my job.


In approx 300 dives I have never had prolonged trouble equalising my ears, nor am I conscious of my own equalisation as I descend/ascend. I fly regularly and have no past experience of ear trouble. I have not recently suffered a cold nor am I coming down with one.
I had a few alcoholic drinks on the first flight, not many, plenty of water and no food since breakfast (work never book me a vegetarian meal)... I did however ensure that I ate something when I took the Malarone, as per instructions.


There does not appear to be any reference to this side effect in the literature accompanying my UK prescribed Malarone, nor online.
All I have found is the following 3 recommendations:

1) From DAN:

Question:
I would be grateful if your medical director could supply me with the recommendations regarding the use of Malarone as malaria prophylaxis when diving. I have a patient who is planning a diving holiday in Kenya. Thank you very much for your help.Answer:
My impression was that Malarone was indicated for treatment of acute uncomplicated falciparum malaria and not for chemoprophylaxis where Paludrine (AstraZeneca) is usually used.
I would not recommend anyone undergoing treatment, with this or any other product for that matter, for malaria to dive.
as for its use in prophylaxis, there is, to my knowledge, no relevant literature on its use as a prophylaxis during diving holidays.
the usual recommendations, which are not completely problem free, is doxycycline but avoid the sun or Lariam but beware of GI and psychotropic effects. the best is the use of repellents and nets but be aware to the small but definitely present risk of infection.​

2) A 2008 or was it 2009 SB post:

Malaria is a real issue here in South - Eastern Africa - but I have never bothered about during my many trips to Phils.

The latest SA DAN mag I got has an article on Malaria prevention, it lists Malarone and says its pretty much good for diving although "Additional sensitivity to motion sickness" has been reported. The one to avoid is Lariam, its hectic on the mind and unsafe for divers.

3) From e-Med
e-med Private Medical Services - Scuba Diving Medical Advice - A to Z of Diving

'So malarone, the newest of the prophylaxis which is taken 2 days before and a week after seems to suit divers best'


Any responses to this post will be appreciated.

Is it likely that my inability to equalise was caused by Malarone?
Has any body heard of or experienced this side effect before?

Thanks,
Nic

 

[Angry Turtle]

I do not have anymore to share other than in my last trip to Roatan, four of us took malarone and had no similar issues.

I did take pseudoephedrine as decongestant for some congestion I was suffering.

 

[Skydiver1]

The purpose of this post is to find out if anybody else has suffered the inability to equalise their middle ear when flying or diving, in the first few days of taking the antimalarial; Malarone

And to suggest that it may be an undocumented side effect.

I therefore apologise if the following documentation of my experience is long winded.

I started taking Malarone 2 days before my flights to Gambia.
No noticeable side effects before flying.
No noticeable side effects during Flight 1; London to Brussels

During Flight 2; Brussels to... tarmac somewhere before taking off again for Gambia I realise that my hearing is very very very muffled. I had not fallen asleep, I guess it just crept up on me. I ask my mate if he has noticed any discernable difference in cabin pressure or had to equalise his ears, he says no.
I loudly ask the people around me the same question and they all stare at me as if I'm mental and then promptly ignore me. Fair enough I was probably being loud and obnoxious on a plane full of people who don't speak English.
The ear situation does not improve.

Upon landing it gets worse, and turns from muffled/cotton wool sound to nagging but tolerable pain.
During take off and ascent the bearable pain becomes unbearable and I sit with my head between my hands with uncontrollable tears streaming down my face for the entire flight (lame), and am unable to equalise no matter how hard I try... I try pretty damn hard.

Upon landing I am very disorientated and confused, last to get through customs because I'm completely 'out of it', and have to pull my luggage off someone else's trolley outside the airport (first few minutes experience in Gambia).
I down a 1.5l water, 2 ibuprofen, 2 paracetamol and fall asleep.

I spend only the one night in Gambia before joining the ship I am to be working on at considerable distance offshore

Side effects continue for 3-4 days including:

• Permanent nausea
• Permanent headache
• Seasickness (which I do not normally suffer from, but its mostly nausea, with seasickness)
• Inability to drink even the smallest amount of water without vomiting -Subsequent dehydration, (exacerbating the headache, and ineffectiveness of the Malarone)
• Confusion/Disorientation (but not as bad as the day I landed)
• Detachment, feeling of 'not being present'
• Lack of appetite (and more vomiting anyway)

Leading to lack of focus and difficulty doing my job

So I opt to miss a day's Malarone and see what happens.
What happens is ALL of the above stop
So I stop taking Malarone
*yes it only takes one mosquito, and yes I did suffer one mosquito bite during the first few days on the ship; there are none left aboard any more. But I could not function well enough to do my job.


In approx 300 dives I have never had prolonged trouble equalising my ears, nor am I conscious of my own equalisation as I descend/ascend. I fly regularly and have no past experience of ear trouble. I have not recently suffered a cold nor am I coming down with one.
I had a few alcoholic drinks on the first flight, not many, plenty of water and no food since breakfast (work never book me a vegetarian meal)... I did however ensure that I ate something when I took the Malarone, as per instructions.


There does not appear to be any reference to this side effect in the literature accompanying my UK prescribed Malarone, nor online.
All I have found is the following 3 recommendations:

1) From DAN:

Question:
I would be grateful if your medical director could supply me with the recommendations regarding the use of Malarone as malaria prophylaxis when diving. I have a patient who is planning a diving holiday in Kenya. Thank you very much for your help.Answer:
My impression was that Malarone was indicated for treatment of acute uncomplicated falciparum malaria and not for chemoprophylaxis where Paludrine (AstraZeneca) is usually used.
I would not recommend anyone undergoing treatment, with this or any other product for that matter, for malaria to dive.
as for its use in prophylaxis, there is, to my knowledge, no relevant literature on its use as a prophylaxis during diving holidays.
the usual recommendations, which are not completely problem free, is doxycycline but avoid the sun or Lariam but beware of GI and psychotropic effects. the best is the use of repellents and nets but be aware to the small but definitely present risk of infection.​

2) A 2008 or was it 2009 SB post:



3) From e-Med
e-med Private Medical Services - Scuba Diving Medical Advice - A to Z of Diving

'So malarone, the newest of the prophylaxis which is taken 2 days before and a week after seems to suit divers best'


Any responses to this post will be appreciated.

Is it likely that my inability to equalise was caused by Malarone?
Has any body heard of or experienced this side effect before?

Thanks,
Nic

I dont know why the DAN doctor said he was under the impression it's not used for prophlyaxis. It obviously is. Maybe it's not licenced for that purpose in his jurisdiction.

It's unlikely that it caused your inability to equalise given it's not listed anywhere in the product information.

I have taken malarone and never experienced that particular adverse effect.

 

[drl]

My husband and I both took Malarone on a trip to Belize (which included time in the rain forest as well as a week on a live aboard) and neither of us experienced any difficulty equalizing.
It sounds like you had a very unpleasant experience; I can't speculate as to whether it was related to the Malarone or something else entirely.

 

[DocVikingo]

Hi MrsBBC,

The manufacturer of Malarone, GlaxoSmithKline (GSK), both in its USA & UK materials, states under Indications and Usage that: "Malarone is indicated for the prophylaxis of P. falciparum malaria, including in areas where chloroquine resistance has been reported."

Malarone has wide-spread use in the prevention of malaria in travelers on vacation. Typically, this drug is relatively well tolerated. The most common adverse reactions are headache, nausea, vomiting, fever, muscle ache & abdominal pain. Loss of appetite also occasionally has been reported.

As for research support for such use, including in travelers, see for example: J Antimicrob Chemother. 2007 Nov;60(5):929-36.A systematic review and meta-analysis of the effectiveness and safety of atovaquone proguanil (Malarone) for chemoprophylaxis against malaria. Nakato H, Vivancos R, Hunter PR.SourceSchool of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK.

Paludrine (proguanil hydrochloride) (AstraZeneca) really is no longer recommended as a sole chemoprophyoactic agent in most situations. The most recent version of the UK's HPA Guidelines for malaria prevention in travellers from the United Kingdom
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1203496943523 indicates: "There are very few regions in the world where the local Plasmodium falciparum strains are fully sensitive to proguanil, so prophylaxis with proguanil as a single agent is rarely appropriate." I would add that Gambia is not one of these "very few regions."

Turing to the ear/equalization issue, Malarone has been associated with tinnitus (ringing in the ears) & hearing loss in a very small number of users. These are not common side effects. What you are complaining of sounds more like a congestion-related problem in the absence of a cough or symptoms of an upper respiratory infection, and I am unaware of any literature suggesting that Malarone contributes to such.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[MrsBBC]

Thanks Doc, and everyone else,

So the suggestion/indication is; that my inability to equalise is most likely congestion related even though I have at no point felt congested, or ill.
As such, it is unlikely to be a personal side effect to the Malarone that would repeat itself if I were to take it again (e.g. when on a dive holiday and not abroad for work).

As Malarone is commonly recommended for many malarial diving regions I should be fine to take Malarone again...
If I can get past the other bloody side effects.

Nic

P.S. Any other input still appreciated

 

[DocVikingo]

Hi Nic,

It can't be absolutely ruled out that Malarone is not causing this symptom constellation, but it appears rather improbable.

Yes, Malarone is commonly recommended for many malarial diving regions, and for good reason. However, should you decide to take it again on a future trip, it would be prudent to start the drug far enough before departure to assess for adverse reaction.

As you are aware, the customary regimen is to start dosing 1-2 days prior to traveling into a malaria risk area. However, there is no evidence to suggest that starting the drug, say, 5-days or so before departure poses any risk for a normal dive vacation. Numerous studies have been done on the long-term use of Malarone and to date have produced nothing of real concern to the healthy individual.

Of course such a plan would require the approval of the prescribing physician.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[Skydiver1]

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

Interesting how every post has to signed off with this. What a nasty little litigious world we live in.