How many days should dexamethasone (DEXA) be given before starting albendazole?

Timing of Dexamethasone Administration Before Albendazole in Neurocysticercosis

Dexamethasone should be started at least one day before initiating albendazole therapy for neurocysticercosis to reduce inflammatory reactions and prevent neurological complications. 1

Rationale for Pre-Treatment with Corticosteroids

Corticosteroids are essential when administering antiparasitic drugs like albendazole for neurocysticercosis because:

• Antiparasitic drugs cause parasite death, which triggers inflammatory reactions in the brain
• This inflammation can lead to increased intracranial pressure, seizures, and neurological deterioration
• Pre-treatment with corticosteroids mitigates these inflammatory responses

Recommended Administration Protocol

1. Start dexamethasone one day before albendazole 1
2. Continue dexamethasone throughout the albendazole treatment course (typically 10-14 days)
3. Consider tapering dexamethasone after 7 days if clinical improvement is observed and no significant cerebral edema is present on imaging

Dosing Recommendations

• Dexamethasone: 6-8 mg/day initially, with higher doses (8 mg/day for 28 days followed by taper) showing better seizure control in clinical trials 1
• Albendazole: 15 mg/kg/day (maximum 1200 mg/day) divided into 2 daily doses for 10-14 days 1, 2

Special Considerations

Cysticercal Encephalitis

• In patients with diffuse cerebral edema (cysticercal encephalitis), antiparasitic drugs should be avoided initially
• Focus on treating the cerebral edema with corticosteroids first 1
• Only consider antiparasitic therapy after edema has resolved

Hydrocephalus

• In patients with untreated hydrocephalus, manage elevated intracranial pressure first before administering antiparasitic drugs 2
• Consider surgical intervention (shunting) before antiparasitic therapy

Drug Interactions

• Dexamethasone can reduce the bioavailability of praziquantel 3
• However, dexamethasone increases plasma concentrations of albendazole sulfoxide (the active metabolite) 3

Monitoring During Treatment

• Monitor for hepatotoxicity and leukopenia in patients treated with albendazole for >14 days 1
• Check baseline complete blood count and liver function tests before starting therapy 2
• Monitor blood counts at the beginning of treatment and every 2 weeks 2

Common Pitfalls to Avoid

1. Failure to screen for ocular cysticercosis: Always perform fundoscopic examination before starting antiparasitic therapy to avoid triggering inflammation in ocular lesions 2

2. Not screening for strongyloidiasis: Screen for Strongyloides stercoralis before starting corticosteroids to prevent hyperinfection syndrome 1, 2

3. Starting albendazole without corticosteroid pre-treatment: This can lead to severe neurological deterioration due to inflammatory reactions 1

4. Using prolonged corticosteroids without proper monitoring: Monitor blood glucose and consider bone and stomach protection measures 1

By following these guidelines, you can minimize the risk of treatment-related complications and optimize outcomes for patients with neurocysticercosis.