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How to Treat Neurocysticercosis?

Things to note:
  • Health education.
  • Surgery for treatable ventricular blockage or spinal or intraocular cysts.

Medical Treatemnt:
For active or viable cysts only:
* Albendazole, oral, twice daily for 8 days only for active or viable cysts.
  • > 60 kg: 400 mg.
  • < 60 kg: 7,5 mg / kg to 800 mg daily maximum.
  • In pregnancy, do not use.
For a period of up to one year, progressive recovery may occur.
Drug- induced cysticer damage can lead to an acute inflammatory reaction, whose intensity is related to the number of viable cysts and can cause cerebral oedema.
This reaction is minimized by the addition of corticosteroids, e.g:
* Prednisone, oral, 60 mg daily for 8 days.
Anticonvulsants, if required.
The objective is to use monotherapy, i.e. a single anticonvulsant, to increase the dose gradually until the seizures are controlled or clinically significant side effects occur.
If the initial medicine does not achieve satisfactory control with optimal dosages or causes unacceptable adverse effects, a second medicine can be started. The first medicine should be continued for 2 weeks and gradually decreased over 6 to 8 weeks until it is stopped.
If the second medicine fails and alcohol and poor adhesion is excluded, combination therapy may be necessary. Refer to specialist examination patients.Patients with a history of myoclonic seizures or typical absence of valproate should preferably be treated, as the use of either phenytoin or carbamazepine may aggravate these seizures.
Drug level monitoring is not helpful except:
  • Confirm toxicity in a symptomatic patient.
  • Confirm poor adhesion.
  • Although good self- reported adherence with poor control.
  • When dose increases beyond doses exceeding 5 mg / kg per day or 300 mg per day with phenytoin are considered.
Partial seizures or generalised tonic clonic seizures
The choice between therapeutic agents must be based on the acceptability of side effects and the lifestyle of the number of doses.
* Oral carbamazepine.
  • Start with 12 hours of 100 mg.
  • Increase in weekly intervals of 100-200 mg / day depending on seizure control and adverse events.
  • Maximum usual dose: 600 mg 12 hours per day.
Oral, Lamotrigin.
  • 25 mg 2 weeks daily, then 50 mg 2 weeks daily.
  • Increase by 50 mg every 2 weeks depending on the response.
  • Usual maintenance dose: 100-200 mg per day or 12 hours per dose.
Phenytoin, oral, 4.5-5 mg/kg (on lean body mass) daily.
  • Usual starting dose in an adult male: 300mg once daily.
  • Dose changes above 300 mg should be done only in no more than 50 mg increments at intervals no shorter than 2 weeks.
For patients who are not stabilized or who do not tolerate the above drugs:
* Valproate, oral.
  • Common starting dose: 200-300 mg 12 hours per day.
  • Increase to a maximum daily dose of 1 200 mg 12 hours each 2 weeks, as required.
  • Other epilepsy types
    • In consultation with a specialist, manage.
    • For certain indications, clonazepam may be used.
    In certain circumstances, Phenobarbitone may be considered. It has a long life and can be taken once every day. Sedation is a common side effect.
    HIV-infected individuals on ARVs
    Enzymes that induce anti- epileptic drugs are phenytoin and carbamazepine. Patients switch to lamotrigine or valproate using these anti- epileptics due to potential drug interactions with antiretroviral drugs.
    * Oral, Lamotrigin.
    • 25 mg 2 weeks daily, then 50 mg 2 weeks daily.
    • Increase by 50 mg every 2 weeks depending on the response.
    • Usual maintenance dose: 100-200 mg per day or 12 hours per dose.
    Lopinavir / ritonavir and atazanavir induce the metabolism of lamotrigine. The dose of lamotrigine should be doubled every 2 weeks when patients are switched to a regimen containing lopinavir / ritonavir or atazanavir.
    Lamotrigine is preferred to valproate in HIV- infected women of childbearing age.
    * Valproate, oral.
    • Common starting dose: 200-300 mg 12 hours per day.
    • Increase to a maximum daily dose of 1200 mg 12 hours, as required, every 2 weeks.
    Add valproate therapy:
    * Lamotrigine, oral.
    • Start with 25 mg daily for 2 weeks in alternate days, up to 25 mg daily for 2 weeks.
    • Depending on the response, increase by 25-50 mg every 2 weeks.
    Status epilepticus:
    To prevent permanent brain damage, seizure control should take place within 60 minutes.
    Initial Treatment:
    • Lorazepam, IV / IM, 4 mg.
    • Diazepam, IV, 10- 20 mg, 2 mg / minute no faster.
    * IV Clonazepam, 2 mg.
    • May be repeated 5 minutes later.
    • Dose maximum: 4 mg.
    * Midazolam, buccal, 5-10 mg using the contents of an ampoule.
    • If convulsions continue repeat the dose.
    * Phenytoin, IV, 20 mg / kg diluted 0.9 percent( not dextrose) of sodium chloride administered at a rate not exceeding 50 mg / min, preferably with cardiac monitoring.
    • If arrhythmias occur, temporarily interrupt the infusion and slowly reintroduce.
    Seizures continuing after 30 minutes
    Patients intubate and ventilate.
    * Thiopental sodium, IV, 2- 4 mg / kg, followed every 2- 3 minutes by 50 mg bolus for seizure control.
    • Dose of maintenance: 1- 5 mg / kg / hour.
    • Attention to hypotension.
    • Once 24 hours of seizures have been controlled, wean off thiopental sodium by reducing the dose by 1 mg / kg every 12 hours.
    * Propofol, IV, 3-5 mg/kg/dose as a bolus.
    • Dose Maintenance: 30-100 mcg / kg / minute.
    In patients with thiopental sodium, higher initial maintenance doses of phenytoin may be required. Doses should be controlled by daily monitoring of therapeutic drugs until phenytoin levels have stabilized after thiopental sodium has been removed.
    If seizures controlled:
    * Phenytoin, IV, 100 mg 8 hourly oral, 300 mg daily when seizures are controlled.
    • Initial maintenance should not be more than 12 hours after loading.
    • The clinical signs of controlled seizures are autonomic stability and lack of abnormal movement.
    Optimal control of epilepsy on a single agent is the best management. Do not initiate valproate during pregnancy, as it is associated with a higher teratogenic potential than the other first line agents.
    Before pregnancy is considered, folate supplementation:
    * Folic acid, oral, 5 mg daily.
    • Pregnancy alters drug levels, adjust dose according to levels.
    Prophylaxis in head trauma
    Phenytoin may be of benefit during initial period following significant head trauma. For dose, see medicine treatment.