Current Trends Adverse Reactions to Fansidar and Updated
Recommendations for Its Use in the Prevention of Malaria
Since pyrimethamine-sulfadoxine (Fansidar) became available in
the
United States in 1982, it has been an integral part of the malaria
prophylaxis regimen that CDC recommends for travelers at risk of
exposure to chloroquine-resistant Plasmodium falciparum (CRPF). As
the areas of the world with transmission of CRPF have expanded, the
number of U.S. travelers using Fansidar has increased. Fansidar is
usually well tolerated; however, as with other sulfonamides, severe
adverse reactions associated with its use have been reported (1-5).
During the past 3 months, additional cases to those reported in the
literature of severe cutaneous reactions (erythema multiforme,
Stevens-Johnson syndrome, and toxic epidermal necrolysis)
associated
with the use of Fansidar over the past 2 years have been reported
to
CDC. These 10 cases (four fatal) that have occurred among U.S.
travelers are currently being investigated by CDC in coordination
with
the U.S. Food and Drug Administration and the drug manufacturer.
In
addition, there is a collaborative effort under way to assess the
risks associated with the use of this drug for malaria prophylaxis.
Until the risk of adverse reactions to Fansidar is more
thoroughly
defined, CDC recommends the following:
Chloroquine remains the primary drug of choice for
travelers
to all malarious areas (6).
When considering the use of Fansidar for chemoprophylaxis
of
CRPF, physicians should carefully question travelers regarding
any
previous history of sulfonamide intolerance. Fansidar should
not
be prescribed if there is any history of previous untoward
reaction to sulfonamides.
Travelers to CRPF regions in Asia or South America should
take Fansidar in addition to chloroquine only if they stay
overnight in rural areas. Travelers visiting urban areas of
Asia
and South America are at low risk of acquiring malaria, as are
travelers to rural areas during daytime hours, because
Anopheles
mosquitoes bite during the evening and nighttime hours.
Travelers to areas of east and central Africa where
transmission of CRPF has been documented should continue to use
the combination of chloroquine and Fansidar. The risk of
acquiring CRPF in these areas is substantial because of the
intense transmission of malaria, especially in those rural
areas
usually frequented by tourists.
Travelers should be advised to discontinue Fansidar use
immediately in the event of a possible ill effect, especially
if
any mucocutaneous signs or symptoms develop, such as pruritus,
erythema, rash, orogenital lesions, or pharyngitis.
Travelers should be informed that, regardless of the
prophylactic regimen employed, it is still possible to contract
malaria. Medical attention should be sought promptly in the
event
of a febrile illness, and the physician should be advised of
the
recent travel history and possibility of exposure to malaria.
The above recommendations differ from earlier statements and
should be applied as the most current information available (6-8).
CDC will update these interim malaria chemoprophylaxis
recommendations
in the near future. Additional cases of adverse reactions to
Fansidar
should be reported to the Malaria Branch, Division of Parasitic
Diseases, Center for Infectious Diseases, CDC, telephone (404)
452-4046.
Reported by Malaria Br, Div of Parasitic Diseases, Center for
Infectious Diseases, Div of Quarantine, Center for Prevention Svcs,
CDC.
References
Olsen VV, Loft S, Christensen K. Serious reactions during
malaria
prophylaxis with pyrimethamine-sulfadoxine (Letter). Lancet
1982;II:994.
Whitfield D. Presumptive fatality due to
pyrimethamine-sulfadoxine (Letter). Lancet 1982;II:1272.
Hornstein OP, Ruprecht KW. Fansidar-induced Stevens-Johnson
syndrome (Letter). N Engl J Med 1982;307:1529-30.
Ligthelm RJ, van Zwienen J, Stuiver PC, Djajadiningrat AP.
Syndroom van Stevens-Johnson en granulopenie tijdens het
gebruik
van sulfadoxine-pyrimethamine (Fansidar). Ned Tijdschr Geneesk
1983;127:1735-7.
Setia U. Fansidar-induced Stevens-Johnson syndrome and malaria
prophylaxis (Letter). Pediatr Infect Dis 1983;2:173-4.
CDC. Prevention of malaria in travelers 1982. MMWR
1982;31:1S-28S.
CDC. Imported malaria among travelers--United States. MMWR
1984;33:388-90.
CDC. Health information for international travel 1984.
Atlanta,
Georgia: Centers for Disease Control, 1984; HHS publication
no.
(CDC)84-8280;33:11-58.
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