LETTERS TO THE EDITOR 4. Gullahorn GM, Bohman HR, Wallace MR. Anaesthesia emergence delirium after mefloquine prophylaxis. Lancet. 1993;341:632. 5. Ritchie EC, Block J, Nevin RL. Psychiatric side effects of mefloquine: Applications to forensic psychiatry. J Am Acad Psychiatry Law. 2013;41:224-235. 6. Magill A, Cersovsky S, DeFraites R. Advising travelers with specific needs: special considerations for US military deployments. In: Brunette GW, ed. CDC Health Information for International Travel: The Yellow Book 2012. New York: Oxford University Press; 2012:561-566. 7. Behrens CJ, Ul Haq R, Liotta A, Anderson ML, Heinemann U. Nonspecific effects of the gap junction blocker mefloquine on fast hippocampal network oscillations in the adult rat in vitro. Neuroscience. 2011;192:11-19. 8. Bissiere S, Zelikowsky M, Ponnusamy R, et al. Electrical synapses control hippocampal contributions to fear learning and memory. Science. 2011;331:87-91. 9. Garcia-Rill E, Heister DS, Ye M, Charlesworth A, Hayar A. Electrical coupling: novel mechanism for sleep-wake control. Sleep. 2007;30:1405-1414. 10. Beck P, Odle A, Wallace-Huitt T, Skinner RD, Garcia-Rill E. Modafinil increases arousal determined by P13 potential amplitude: an effect blocked by gap junction antagonists. Sleep. 2008; 31:1647-1654. 11. Dow G, Bauman R, Caridha D, et al. Mefloquine induces dose-related neurological effects in a rat model. Antimicrob Agents Chemother. 2006;50:1045-1053. 12. Nevin RL. Mefloquine prescriptions in the presence of contraindications: prevalence among US military personnel deployed to Afghanistan, 2007. Pharmacoepidemiol Drug Saf. 2010;19:206-210. 13. Department of Defense: Office of the Assistant Secretary of Defense for Health Affairs. Memorandum, subject: service review of mefloquine prescribing practices, January 17, 2012. http://dx.doi.org/10.1016/j.jopan.2013.09.003
Reply: Possible Confounding by Mefloquine in the Association of Emergence Delirium With PTSD and TBI Among Combat Veterans
To the Editor: The letter by Dr. Nevin to the Journal of PeriAnesthesia Nursing regarding the possible confounding variability that mefloquine hydrochloride prophylaxis may contribute to the incidence of and risk factors for emergence delirium (ED)1 is not only intriguing but also very timely. The U.S. Food and Drug Administration recently published a safety announcement on the prescriptive use of mefloquine to include a black box warning.2 As Dr. Nevin clearly described, the potential irreversible psychiatric and neurologic problems associated with its use
335
must drive the scientific community to conduct further research in this area. The US military’s use of mefloquine hydrochloride for malaria prophylaxis has a long history. Secondary to the known problems associated with its use, prescriptions for primary prophylactic use have been on a steady decline.3 From our own personal experience with taking the medication during combat zone deployments, we are all too familiar with the sleep disturbances (during normal physiologic sleep) and other associated side effects attributed to its use as malarial prophylaxis.4 It is important for your readers to recognize that although a history of mefloquine use may indeed be a confounding factor as previously described, the etiology of ED is multifactorial.5,6 As prescriptive use of mefloquine continues to decline, we believe that the observed incidence of ED continues to be a frequent complication among our US military members who have returned from combat deployment. Whether secondary to a history of mefloquine treatment, anxiety continues to be a major predictor.1 Implications for future research should include a retrospective look into those military members who have displayed the signs and symptoms of ED to discover the relationship between individual use of mefloquine and ED. Future prospective studies should also meticulously describe mefloquine use among combat veterans that present for surgery to describe the plausible relationship it may have with ED. This may be a great opportunity to collaborate with Dr. Nevin so that we can continue our pursuit of improved health care for our nation’s finest. Jason M. McGuire, PhD, CRNA Commander, Nurse Corps, U.S. Navy, and Assistant Professor Graduate School of Nursing Uniformed Services University of the Health Sciences Bethesda, MD E-mail: [email protected] John Tyler Wilson, PhD, CRNA Major, Nurse Corps, U.S. Army, and Assistant Professor Graduate School of Nursing Uniformed Services
LETTERS TO THE EDITOR
336
University of the Health Sciences Bethesda, MD E-mail: [email protected]
Disclaimer: The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States government.
References 1. McGuire JM. The incidence of and risk factors for emergence delirium in U.S. military combat veterans. J PeriAnesthesia Nurs. 2012;27:236-245.
2. U.S. Food and Drug Administration. FDA Approves Label Changes for Antimalarial Drug Mefloquine Hydrochloride Due to Risk of Serious Psychiatric and Nerve Side Effects. Drug Safety Communications, http://www.fda.gov/Drugs/Drug Safety/ucm362227.htm; 2013. Accessed September 11, 2013. 3. Kersgard CM, Hickey PW. Adult malaria chemoprophylaxis prescribing patterns in the military health system from 2007-2011. Am J Trop Med Byg. 2013;89:317-325. 4. Toovey S. Mefloquine neurotoxicity: A literature review. Trav Med Infect Dis. 2009;7:2-6. 5. Gullahorn GM, Bohman HR, Wallace MR. Anaesthesia emergence delirium after mefloquine prophylaxis. Lancet. 1993;341:632. 6. McGuire JM, Burkard JF. Risk factors for emergence delirium in U.S. military members. J PeriAnesthesia Nurs. 2010; 25:392-401. http://dx.doi.org/10.1016/j.jopan.2013.09.007
Reply: Possible Confounding by Mefloquine in the Association of Emergence Delirium With PTSD and TBI Among Combat Veterans
To the Editor: The letter by Dr. Nevin to the Journal of PeriAnesthesia Nursing regarding the possible confounding variability that mefloquine hydrochloride prophylaxis may contribute to the incidence of and risk factors for emergence delirium (ED)1 is not only intriguing but also very timely. The U.S. Food and Drug Administration recently published a safety announcement on the prescriptive use of mefloquine to include a black box warning.2 As Dr. Nevin clearly described, the potential irreversible psychiatric and neurologic problems associated with its use
335
must drive the scientific community to conduct further research in this area. The US military’s use of mefloquine hydrochloride for malaria prophylaxis has a long history. Secondary to the known problems associated with its use, prescriptions for primary prophylactic use have been on a steady decline.3 From our own personal experience with taking the medication during combat zone deployments, we are all too familiar with the sleep disturbances (during normal physiologic sleep) and other associated side effects attributed to its use as malarial prophylaxis.4 It is important for your readers to recognize that although a history of mefloquine use may indeed be a confounding factor as previously described, the etiology of ED is multifactorial.5,6 As prescriptive use of mefloquine continues to decline, we believe that the observed incidence of ED continues to be a frequent complication among our US military members who have returned from combat deployment. Whether secondary to a history of mefloquine treatment, anxiety continues to be a major predictor.1 Implications for future research should include a retrospective look into those military members who have displayed the signs and symptoms of ED to discover the relationship between individual use of mefloquine and ED. Future prospective studies should also meticulously describe mefloquine use among combat veterans that present for surgery to describe the plausible relationship it may have with ED. This may be a great opportunity to collaborate with Dr. Nevin so that we can continue our pursuit of improved health care for our nation’s finest. Jason M. McGuire, PhD, CRNA Commander, Nurse Corps, U.S. Navy, and Assistant Professor Graduate School of Nursing Uniformed Services University of the Health Sciences Bethesda, MD E-mail: [email protected] John Tyler Wilson, PhD, CRNA Major, Nurse Corps, U.S. Army, and Assistant Professor Graduate School of Nursing Uniformed Services
LETTERS TO THE EDITOR
336
University of the Health Sciences Bethesda, MD E-mail: [email protected]
Disclaimer: The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States government.
References 1. McGuire JM. The incidence of and risk factors for emergence delirium in U.S. military combat veterans. J PeriAnesthesia Nurs. 2012;27:236-245.
2. U.S. Food and Drug Administration. FDA Approves Label Changes for Antimalarial Drug Mefloquine Hydrochloride Due to Risk of Serious Psychiatric and Nerve Side Effects. Drug Safety Communications, http://www.fda.gov/Drugs/Drug Safety/ucm362227.htm; 2013. Accessed September 11, 2013. 3. Kersgard CM, Hickey PW. Adult malaria chemoprophylaxis prescribing patterns in the military health system from 2007-2011. Am J Trop Med Byg. 2013;89:317-325. 4. Toovey S. Mefloquine neurotoxicity: A literature review. Trav Med Infect Dis. 2009;7:2-6. 5. Gullahorn GM, Bohman HR, Wallace MR. Anaesthesia emergence delirium after mefloquine prophylaxis. Lancet. 1993;341:632. 6. McGuire JM, Burkard JF. Risk factors for emergence delirium in U.S. military members. J PeriAnesthesia Nurs. 2010; 25:392-401. http://dx.doi.org/10.1016/j.jopan.2013.09.007
