DEAR DR. ROACH: My wife and I are planning a three-week trip to South Africa and three other countries nearby. We need to take the antimalaria drug Malarone for 26 days, so we did a trial run of four tablets each. Shortly after our first dose, my wife got very itchy skin on her head, ears and upper body that continued for several days after we finished the four pills. There were no hives or rashes with the itchiness.

Itchiness is listed as a common side effect; however, we are very concerned that this could progress to a more serious reaction, such as anaphylactic shock. Do you think this would be likely? Would carrying an epinephrine pen be a reasonable response in case of a more severe reaction? The alternative antimalaria drugs are not very good options. — Anon.

ANSWER: Malarone is one of the first-line choices to prevent malaria in areas with and without resistance to other drugs. It is safe and effective for most people. The itchiness your wife experienced is common; up to 10% of people may have it, and serious reactions like anaphylaxis are quite rare. I do not think an epinephrine pen is necessary.

Before Malarone was available, mefloquine was a commonly used preventive medication for malaria. This medicine caused strange dreams in many people taking it.

Finally, I wonder if your math is right. We recommend starting Malarone to two days prior to leaving and continuing it for a week after coming home, so it is 30 days instead if you will be in areas with malaria for exactly three weeks.

DEAR DR. ROACH: I’m 74 years old, and arthritis is rearing its ugly head. Because I’ve had gastric bypass surgery, I take Tylenol for pain. I was told never to take NSAIDs because of possible stomach issues. Can you recommend any pain medication that can control these aches, is safe, and isn’t an opioid? — M.J.

ANSWER: Control of pain is never perfect. We make do with the drugs we have and sometimes use other drugs and non-pharmacologic treatments to help during a program of comprehensive pain management. Although acetaminophen (Tylenol) helps many people, it is often inadequate. For arthritis pain in particular, there are several other types of treatment to consider:

The most important, in my opinion, is not a drug at all. Regular exercise is the first treatment for mild to moderate arthritis. Many people are reluctant to exercise with arthritis as they feel that their arthritis was caused by exercise, which probably isn’t the case for most people. Although arthritis can come on after joint trauma, most arthritis is not caused by or worsened due to exercise. In fact, both pain and disability are decreased with a regular exercise program, and the ability to tolerate exercise improved.

Topical NSAIDs, such as diclofenac gel, are safe in people with stomach issues and are helpful for some people with pain in their superficial joints, such as the hands, wrists, elbows and knees. Some antidepressants such as amitriptyline and duloxetine reduce but don’t eliminate pain. Some seizure medicines like gabapentin are useful.

Many of my patients use supplements to help arthritis. Glucosamine/chondroitin, turmeric (or curcumin), Boswellia, and S-adenosyl methionine are all supplements that have some benefit. Much of the benefit from these supplements is caused by people expecting it to work (a placebo effect), but all of these are generally considered safe.

Finally, nerve blocks and even surgery can be considered in people with more severe arthritis who don’t respond to other treatments.

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