The Quinism Foundation Calls on the Department of Veterans Affairs to Screen Recent Veterans for Symptomatic Mefloquine Exposure

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The Antimalarial Drug Can Cause Chronic Neurologic and Psychiatric Effects Among Some Veterans, but the Government Does Not Know How Many Veterans Were Exposed, and Which Veterans Are Suffering Symptoms of Poisoning from their Exposure

The Quinism Foundation has sent correspondence to the Acting Secretary of Veterans Affairs (VA) and current Under Secretary of Defense for Personnel and Readiness, Robert Wilkie, calling upon the VA to implement universal screening of recent veterans for a history of symptomatic exposure to the antimalarial drug mefloquine (previously marketed in the U.S. as Lariam®).

Mefloquine has been widely used by the Department of Defense (DoD), particularly for the prevention (or prophylaxis) of malaria among U.S. military personnel, since it was licensed by the U.S. Food and Drug Administration (FDA) in 1989.

In 2013, after nearly a quarter-century of use by DoD, the FDA warned that mefloquine can cause long-lasting and even permanent adverse effects. The DoD has since declared mefloquine “a drug of last resort,” and has all but eliminated the drug’s use.

However, recent media coverage has revealed that the VA is unable to account for which service members were previously exposed to the drug, and which veterans may be affected [1]. In 2012, the Assistant Secretary for Defense for Health Affairs, in a memorandum from a subordinate office within Wilkie’s current department at DoD [2], conceded that, “Some deploying Service members have been provided mefloquine for malaria prophylaxis without appropriate documentation in their medical records and without proper screening for contraindications.”

“Mefloquine exposure is the cause of a hidden epidemic,” said Remington Nevin, MD, MPH, DrPH, executive director of The Quinism Foundation. “The lasting effects of mefloquine are undoubtedly the cause of mental and physical disability among veterans, but because documentation is so poor, neither VA nor DoD have any idea how large or how serious this epidemic is.”

Recent research confirms that nightmares and other abnormal dreams affect nearly 1 in 7 of those exposed to mefloquine [3], and that more than 1 in 5 of those who complain of nightmares report this symptom continuing as long as three years after exposure [4]. Authors at the U.S. military’s Walter Reed Army Institute of Research (WRAIR), where mefloquine was developed, have noted [5] that “mefloquine toxicity can persist for several years after exposure has been discontinued, with little to no abatement in symptoms over time. Furthermore, given the overlapping symptoms of post-traumatic stress disorder and mefloquine toxicity, it can be challenging to distinguish between the two diagnoses.”

“Screening for symptomatic exposure during a clinical encounter can be as quick and simple as asking the veteran ‘Did you take mefloquine’, and if so, ‘While you were taking the drug, did you experience one or more of these symptoms?’” said Dr. Nevin. “If the veteran reports symptomatic exposure, clinicians should retain an index of suspicion that any chronic neurologic or psychiatric symptoms, including those reported, could represent effects of mefloquine poisoning, a medical condition also known as chronic quinoline encephalopathy or neuropsychiatric quinism.”

Although the VA has recently awarded several disability claims to veterans for permanent neuropsychiatric conditions including anxiety and insomnia that the VA has concluded were due to exposure to mefloquine while serving in the military [6], Dr. Nevin cautions that, “these are likely the tip of a very large iceberg.”

“For every mefloquine veteran who has been successfully awarded service-connected disability compensation by the VA, I am personally aware of several others with disabilities caused by mefloquine poisoning who have been denied compensation, either because their clinicians have misattributed these to non-service-connected conditions, or because the veteran is missing documentation of exposure,” said Dr. Nevin. “Screening for symptomatic mefloquine exposure is a necessary first step to raising VA clinicians’ awareness of the prevalence of mefloquine poisoning among the recent veteran population. Screening will also permit the VA to estimate the total number of veterans exposed, how incomplete prescribing documentation may be, and how many veterans may be suffering disability who may become eligible for compensation.”

About The Quinism Foundation

The Quinism Foundation promotes and supports education and research on quinism, the family of medical disorders caused by poisoning by quinoline drugs, including mefloquine and tafenoquine. Founded in January 2018, the Quinism Foundation is supported by private donations and is advised by an international committee chaired by Mr. Andrew Bryce, of Dublin, Ireland. The Foundation’s board of directors includes retired U.S. Navy Commander William Manofsky, retired U.S. Army Lieutenant Colonel Gregory Alderete; Michael Little, U.S. Navy Petty Officer 2nd Class, Individual Ready Reserve; and retired U.S. Army Colonel and former psychiatry consultant to the Army Surgeon General Dr. Elspeth Cameron Ritchie.

Dr. Nevin is a board-certified occupational medicine and preventive medicine physician and former U.S. Army medical officer and epidemiologist. He is author of more than 30 scientific publications on malaria and the quinoline antimalarials, including “Screening for Symptomatic Mefloquine Exposure”, published in Federal Practitioner (see: https://www.mdedge.com/fedprac/article/132560/mental-health/screening-symptomatic-mefloquine-exposure-among-veterans).

1. McCarren, A. Veterans say anti-malarial drug they were ordered to take isn't in medical records. May 1, 2018 (see: https://www.wusa9.com/article/news/local/veterans-say-anti-malarial-drug-they-were-ordered-to-take-isnt-in-medical-records/65-547667488).
2. Assistant Secretary of Defense for Health Affairs. Memorandum Dated 17 Jan 2012, Subject: Service Review of Mefloquine Prescribing Practices.
3. Tickell-Painter M, Maayan N, Saunders R, et al. Mefloquine for preventing malaria during travel to endemic areas. The Cochrane Database of Systematic Reviews. 2017;10(10):CD006491.
4. Ringqvist Å, Bech P, Glenthøj B, et al. Acute and long-term psychiatric side effects of mefloquine: A follow-up on Danish adverse event reports. Travel Medicine and Infectious Disease. 2015;13(1):80–88.
5. Livezey J, Oliver T, Cantilena L. Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine. Drug Safety Case Reports. 2016;3(1):7.
6. Nevin RL, Ritchie EC. FDA Black Box, VA Red Ink? A Successful Service-Connected Disability Claim for Chronic Neuropsychiatric Adverse Effects From Mefloquine. Federal Practitioner. 2016;33(10):20–24.

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