Can You Take Malarone While Pregnant, Breastfeeding, or With Other Medications? A Physician's Guide

Malarone is generally not recommended during pregnancy due to limited safety data on proguanil in this population, and the CDC recommends alternative antimalarials like chloroquine (in chloroquine-sensitive regions) or mefloquine for pregnant travelers who cannot avoid or postpone travel to a malaria-risk area. Breastfeeding parents face a separate consideration: because Malarone is not well studied in infants under 5 kg, it is generally avoided for infants below that weight, though there is limited data on its use during breastfeeding of larger infants. This guide covers what current guidance says about pregnancy and breastfeeding, walks through the medications that can interact with Malarone, and clarifies a point that trips up a lot of travelers: unlike some other antimalarial drugs, Malarone does not require G6PD testing before you start it.

Quick answer: pregnancy, breastfeeding, and interactions

• Pregnancy: Malarone is generally not recommended due to limited data on proguanil safety in pregnancy. The CDC recommends alternatives such as chloroquine (where the malaria is chloroquine-sensitive) or mefloquine for pregnant travelers who need antimalarial prophylaxis.
• Breastfeeding: Not well studied in infants under 5 kg (about 11 lbs) and generally avoided for that weight range; discuss with a clinician for breastfeeding of larger infants.
• Best option if pregnant or breastfeeding and traveling: The safest option is always to postpone travel to a malaria-risk area if possible. If travel cannot be avoided, your clinician will weigh the specific destination's resistance patterns to choose the right alternative.
• Key drug interactions: Rifampin, rifabutin, tetracycline, and metoclopramide can reduce Malarone's effectiveness; efavirenz (an HIV medication) can also lower atovaquone levels significantly.
• G6PD testing: NOT required for Malarone. This is a common point of confusion because G6PD testing is required for tafenoquine and recommended for primaquine, two other antimalarial drugs. Malarone does not carry this requirement.

Malarone during pregnancy

Malaria infection during pregnancy carries serious risks to both parent and fetus, including higher rates of severe disease, miscarriage, and low birth weight, which is why the CDC's overarching guidance for pregnant travelers is to avoid travel to malaria-risk areas whenever possible. When travel truly cannot be postponed or avoided, prevention still matters, but Malarone is generally not the first choice.

Why Malarone is generally avoided in pregnancy: The available safety data on proguanil use during pregnancy is limited, and current guidance reflects that data gap rather than confirmed evidence of harm. This is a "we don't have enough data to say it's safe" situation more than a "we know it's unsafe" situation, but it is enough for major guidance bodies to recommend alternatives when suitable ones exist.

What the CDC recommends instead:

• Chloroquine, for travel to regions where the malaria parasite remains chloroquine-sensitive.
• Mefloquine, for travel to regions with chloroquine resistance, which describes most malaria-endemic areas globally.

The right choice depends entirely on destination-specific resistance patterns, which is why this decision should be made with a clinician who can review your specific itinerary rather than a generic recommendation.

If you are trying to conceive or find out you're pregnant after starting Malarone: Contact your clinician promptly to discuss your specific situation. Do not stop or continue a malaria prophylaxis regimen without guidance, since both malaria infection and abrupt medication changes carry their own risks.

Malarone during breastfeeding

Guidance here is more nuanced than an outright "avoid it" recommendation. Malarone is not well studied in infants weighing less than 5 kg (about 11 lbs), so it is generally avoided when a breastfeeding infant falls under that weight. For breastfeeding parents with larger infants, data remains limited, and the decision should be individualized with a clinician who can weigh the specific destination's malaria risk against the available (if incomplete) safety information.

As with pregnancy, if travel to a malaria-risk area can be postponed until after breastfeeding or until the infant is older, that is generally the simplest way to avoid the uncertainty altogether. If travel cannot be avoided, discuss both the destination-specific malaria risk and your infant's age and weight with a travel medicine clinician before choosing a prevention strategy.

Malarone drug interactions

Malarone's most clinically relevant interactions involve medications that can lower the blood levels of atovaquone, reducing how well it prevents malaria. If you take any of the following, tell your prescribing clinician before starting Malarone:

Rifampin and rifabutin (used for tuberculosis and some other bacterial infections): These significantly reduce atovaquone concentrations in the blood, which can compromise Malarone's effectiveness. An alternative antimalarial is generally recommended if you are taking either of these medications.

Tetracycline: Can reduce atovaquone levels. If you are taking tetracycline for another reason, discuss alternatives with your clinician.

Metoclopramide (commonly used for nausea): Can reduce atovaquone absorption. This is worth flagging specifically because metoclopramide is sometimes used to manage travel-related nausea, which creates a scenario where a traveler might reach for it without realizing the interaction.

Efavirenz (an HIV antiretroviral medication): Can significantly lower atovaquone levels. Travelers on efavirenz-containing regimens should discuss alternative malaria prevention with both their HIV care provider and a travel medicine clinician.

Warfarin: There is a documented interaction where atovaquone-proguanil can affect warfarin's anticoagulant effect. If you take warfarin, your clinician may want closer INR monitoring while you are on Malarone.

This is not an exhaustive list of every possible interaction. Always give your prescribing clinician your complete current medication list, including over-the-counter medications and supplements, before starting Malarone.

A note on G6PD testing (and why Malarone is different)

Travelers researching antimalarial drugs online frequently encounter G6PD (glucose-6-phosphate dehydrogenase) testing requirements and understandably wonder whether that applies to Malarone too. It does not. G6PD deficiency testing is required before starting tafenoquine and recommended before starting primaquine, because both of those drugs can trigger hemolytic anemia in people with G6PD deficiency. Malarone works through a different mechanism and does not carry a G6PD testing requirement or warning. If you have been told you need G6PD testing for an upcoming trip, confirm with your clinician which specific antimalarial they are recommending, since this detail changes depending on the drug.

Frequently asked questions

Can I take Malarone if I'm pregnant? Malarone is generally not recommended during pregnancy due to limited safety data on proguanil. The CDC recommends chloroquine or mefloquine instead, depending on destination-specific resistance patterns. Postponing travel to malaria-risk areas is the safest option when possible.

Is Malarone safe while breastfeeding? It is generally avoided for breastfeeding infants under 5 kg due to limited safety data in that group. For larger infants, data remains limited, and the decision should be individualized with a clinician.

Does Malarone require G6PD testing before I start it? No. G6PD testing is required for tafenoquine and recommended for primaquine, not Malarone. This is a common point of confusion between different antimalarial drugs.

Can I take Malarone with antibiotics? It depends on the antibiotic. Rifampin, rifabutin, and tetracycline can all reduce Malarone's effectiveness by lowering atovaquone levels. Tell your clinician about any antibiotics you are taking or may need during your trip.

Does Malarone interact with birth control pills? There is no well-established significant interaction between Malarone and hormonal contraceptives, but always disclose your full medication list to your prescribing clinician for a complete review.

What should I do if I'm on efavirenz for HIV and need malaria prevention? Efavirenz can significantly lower atovaquone levels, potentially compromising Malarone's effectiveness. Discuss alternative antimalarial options with both your HIV care provider and a travel medicine clinician.

What antimalarial is recommended instead of Malarone during pregnancy? The CDC recommends chloroquine for travel to chloroquine-sensitive regions or mefloquine for travel to chloroquine-resistant regions. The right choice depends on your specific destination and should be confirmed with a clinician.

Sources

• CDC, Yellow Book: Malaria Chemoprophylaxis: https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/malaria
• CDC, Pregnant Travelers: https://wwwnc.cdc.gov/travel/yellowbook/2024/family/pregnant-travelers
• FDA, Malarone (atovaquone and proguanil hydrochloride) Prescribing Information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021078s023lbl.pdf
• CDC, Choosing a Drug to Prevent Malaria: https://www.cdc.gov/malaria/hcp/drug-malaria/index.html

Medical disclaimer

This article is for general educational purposes and does not replace personalized medical advice. Decisions about antimalarial use during pregnancy, breastfeeding, or alongside other medications should always be made with a licensed clinician who can review your complete health history, current medications, and specific travel itinerary.