Section 603 of the PACT Act Mandates Toxic Exposure Screening, But Current VA Screening Tools Exclude an Assessment of Mefloquine Neurotoxicity
PORT HURON, Mich., Dec. 9, 2024 /PRNewswire-PRWeb/ -- The Quinism Foundation is calling on the VA to screen recent veterans for a history of symptomatic exposure to the neurotoxic antimalarial drug mefloquine (previously marketed in the U.S. as Lariam®) under the toxic exposure screening provisions of section 603 of the Promise to Address Comprehensive Toxics (PACT) Act.
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.
"Among susceptible veterans, mefloquine may act as an idiosyncratic neurotoxicant, potentially causing irreversible brain and brainstem dysfunction," said Dr. Remington Nevin, MD, MPH, DrPH, executive and medical director of The Quinism Foundation. "This drug-induced dysfunction causes a disease of the brain and brainstem called quinoline encephalopathy, or quinism, which can be marked acutely by psychosis, confusion, and risk of suicide, and by lasting psychiatric and neurological symptoms."
"Symptoms of chronic quinoline encephalopathy may include tinnitus, dizziness, vertigo, paresthesias, visual disturbances, nightmares, insomnia, anxiety, agoraphobia, paranoia, cognitive dysfunction, depression, personality change, and suicidal thoughts, among others," said Dr. Nevin. "Particularly among veterans, these symptoms can mimic and be mistaken for those of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI)."
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, but media coverage has revealed that the VA is unable to fully account for which service members were previously exposed to the drug, and which veterans may be affected [1]. The Assistant Secretary for Defense for Health Affairs has 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." [2]
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 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." [5]
"Screening for symptomatic exposure under Section 603 of the PACT Act can be as simple as the VA asking the veteran, 'Did you take mefloquine', and if so, 'While you were taking the drug, did you experience one or more psychiatric symptoms, such as abnormal dreams or nightmares, insomnia, anxiety, depression, restlessness, or confusion?'" said Dr. Nevin. "If the veteran reports symptomatic exposure, VA clinicians should retain an index of suspicion that any chronic neurologic or psychiatric symptoms, including those reported, could represent effects of mefloquine neurotoxicity."
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 notes that, "these are likely the tip of a very large iceberg."
"The lasting effects of mefloquine are undoubtedly the cause of significant mental and physical disability among veterans," said Dr. Nevin, "but because documentation of symptomatic exposure is so poor, neither VA nor DOD have any idea how large or how serious this epidemic is."
"For every mefloquine veteran who has been successfully awarded service-connected disability compensation by the VA, I am aware of several others with disabilities caused by mefloquine neurotoxicity 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 symptomatic exposure," said Dr. Nevin.
"Adding screening for symptomatic mefloquine exposure to the mandated toxic screening under Section 603 of the PACT Act will assist in raising awareness of the prevalence of mefloquine neurotoxicity among the recent veteran population," said Dr. Nevin. "Such screening will also assist VA to estimate the total number of veterans exposed, how incomplete prescribing documentation may be, and how many veterans may be suffering disability who will require compensation."
About The Quinism Foundation
The Quinism Foundation, founded in January 2018, promotes and supports education and research on quinism, the medical disorder caused by quinoline drugs, including mefloquine and tafenoquine.
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).
- 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).
- Assistant Secretary of Defense for Health Affairs. Memorandum Dated 17 Jan 2012, Subject: Service Review of Mefloquine Prescribing Practices.
- 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.
- 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.
- 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.
- 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.
Media Contact
Dr. Remington Nevin, The Quinism Foundation, 1 8102761657, rnevin@quinism.org, quinism.org
SOURCE The Quinism Foundation
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