What is the recommended dose of valproate (anticonvulsant) for treating focal seizures in neurocysticercosis?

Valproate Dosing for Focal Seizures in Neurocysticercosis

For focal seizures in neurocysticercosis, valproate should be administered at an initial dose of 10-15 mg/kg/day, with increases of 5-10 mg/kg/week to achieve optimal clinical response, typically at doses below 60 mg/kg/day. 1

Valproate Dosing Guidelines

• Valproate is administered orally and should be initiated at 10-15 mg/kg/day, with dose increases of 5-10 mg/kg/week until seizures are controlled or side effects occur 1
• Optimal clinical response is usually achieved at daily doses below 60 mg/kg/day, with therapeutic plasma concentrations between 50-100 μg/mL 1
• If the total daily dose exceeds 250 mg, it should be given in divided doses to minimize side effects 1
• The probability of thrombocytopenia increases significantly at total trough valproate plasma concentrations above 110 μg/mL in females and 135 μg/mL in males 1

Antiepileptic Management in Neurocysticercosis

• Seizures secondary to neurocysticercosis usually respond well to first-line antiepileptic drugs, including valproate 2
• Phenytoin (86.08%), valproate (30.38%), clobazam (26.58%), and carbamazepine (10.13%) are commonly used either alone or in combination for seizures in neurocysticercosis 3
• Valproate is a broad-spectrum antiepileptic drug effective against all seizure types, making it suitable for the varied seizure presentations in neurocysticercosis 4
• Antiepileptic drugs should not be abruptly discontinued due to the risk of precipitating status epilepticus 1

Duration of Antiepileptic Therapy

• Withdrawal of antiepileptic drugs can be considered, although residual calcifications on CT scan indicate a high risk of recurrent seizures 2
• For patients with calcific residue following involution of brain parenchymal cysticercosis, long-term antiepileptic treatment is warranted 5
• Antiepileptic drugs can be discontinued after resolution of cystic lesions if no risk factors for recurrence are present 2
• Risk factors for recurrent seizures include: calcifications on follow-up CT, breakthrough seizures, and more than 2 seizures during the course of the disease 2

Antiparasitic Treatment Considerations

• The standard duration of antiparasitic treatment for parenchymal neurocysticercosis with viable cysts is 10 days, and 1-2 weeks for single enhancing lesions 6
• For patients with 1-2 viable cysts, albendazole 15 mg/kg/day in 2 daily doses (up to 1200 mg/day) for 10 days is recommended 6
• For patients with more than 2 viable cysts, combination therapy with albendazole plus praziquantel for 10 days is recommended 6
• Antiparasitic drugs should be avoided in patients with increased intracranial pressure from either diffuse cerebral edema or untreated hydrocephalus 6

Anti-inflammatory Therapy

• Corticosteroids should be used whenever antiparasitic drugs are administered 2
• Dexamethasone at doses between 4.5 and 12 mg/day is frequently used to decrease neurological symptoms 2
• Higher-dose and longer duration (8 mg/day dexamethasone for 28 days followed by taper) has shown fewer seizures compared to shorter courses (6 mg/day for 10 days) 6
• Prednisone at 1 mg/kg/day may replace dexamethasone when long-term steroid therapy is required 2, 7

Important Monitoring and Precautions

• Plasma concentrations of valproate should be measured if satisfactory clinical response has not been achieved, with the therapeutic range being 50-100 μg/mL 1
• Funduscopic examination should be performed before treatment to exclude intraocular cysticerci, as antiparasitic therapy may lead to blindness in these cases 2
• Common side effects of valproate include gastrointestinal disturbances, tremor, weight gain, encephalopathy symptoms, platelet disorders, and liver toxicity 4
• Valproate has drug interaction potential and can increase plasma concentrations of certain coadministered drugs, including phenobarbital and lamotrigine 4