Should steroids be given before albendazole (Anti-parasitic medication) in cases of Neurocysticercosis (NCC)?

Should Steroids Be Given Before Albendazole in Neurocysticercosis?

Yes, corticosteroids should be initiated concomitantly with albendazole, not necessarily before, but they must be given together whenever antiparasitic therapy is used for viable parenchymal neurocysticercosis. 1

Timing and Rationale for Corticosteroid Use

The critical principle is that corticosteroids and albendazole should be started together as adjuvant therapy to prevent inflammatory complications from parasite death. 1, 2

Why Concurrent Administration Matters

• When albendazole kills viable cysts, the dying parasites trigger a severe inflammatory reaction within the brain that peaks during days 11-21 of treatment. 3
• This inflammatory burst causes seizures, increased intracranial pressure, and focal neurological deficits that can be life-threatening if not controlled. 2
• The FDA label explicitly states that oral or intravenous corticosteroids should be considered to prevent cerebral hypertensive episodes during the first week of treatment. 2
• The IDSA/ASTMH guidelines give a "Strong" recommendation (with moderate quality evidence) that corticosteroids should be used whenever antiparasitic drugs are administered, as adjuvant steroid use is associated with fewer seizures during therapy. 1

Optimal Corticosteroid Regimen

The most effective regimen is dexamethasone 8 mg/day for 28 days followed by a 2-week taper, which significantly reduces seizures compared to shorter courses. 3, 4

Evidence Supporting Enhanced Dosing

• A randomized trial comparing conventional dosing (6 mg/day dexamethasone for 10 days) versus enhanced dosing (8 mg/day for 28 days with taper) demonstrated significantly fewer seizure days during antiparasitic treatment (days 1-10: 4 vs. 17, p=0.004) and early after dexamethasone cessation (days 11-21: 6 vs. 27, p=0.014). 4
• The enhanced regimen reduced the number of patients experiencing seizures during treatment (1 vs. 10 patients, p=0.003, NNT=4.6). 4
• Alternative acceptable regimens include dexamethasone 0.1 mg/kg/day for the duration of antiparasitic therapy, or prednisone 1-1.5 mg/kg/day. 3

Treatment Algorithm by Clinical Scenario

For Viable Parenchymal Cysts (1-2 cysts)

• Start albendazole 15 mg/kg/day in 2 divided doses (maximum 1200 mg/day) with food for 10 days. 1
• Simultaneously initiate dexamethasone 8 mg/day for 28 days followed by 2-week taper. 3
• Add antiepileptic drugs if seizures are present. 1

For Multiple Viable Cysts (>2 cysts)

• Start combination therapy: albendazole 15 mg/kg/day plus praziquantel 15 mg/kg/day in 3 divided doses for 10 days. 1
• Simultaneously initiate dexamethasone 8 mg/day for 28 days followed by 2-week taper. 3
• Note that dexamethasone increases albendazole levels by 56% (beneficial) but reduces praziquantel levels through hepatic metabolism, though combination therapy remains superior. 3

For Single Enhancing Lesions

• Start albendazole 15 mg/kg/day in 2 divided doses (maximum 800 mg/day) for 1-2 weeks. 1
• Corticosteroids should be given concomitantly with antiparasitic agents given the data on worsening symptoms without steroids. 1

Critical Contraindications and Pitfalls

When to Avoid Antiparasitic Drugs Entirely

• In cysticercal encephalitis with diffuse cerebral edema, avoid antiparasitic drugs completely and treat with high-dose corticosteroids only (up to dexamethasone 32 mg/day). 1, 3
• Antiparasitic drugs worsen cerebral edema in this setting and can be fatal. 1, 3
• For calcified parenchymal neurocysticercosis, antiparasitic treatment is not recommended as there are no viable cysts. 1

Essential Pre-Treatment Steps

• Perform funduscopic examination before treatment to exclude intraocular cysticerci, as antiparasitic therapy may lead to blindness in these cases. 5
• Obtain pregnancy test in females of reproductive potential, as albendazole causes fetal harm. 2
• Ensure hydrocephalus is treated before starting antiparasitic drugs, as increased intracranial pressure is a contraindication. 5

Common Pitfall: Premature Steroid Discontinuation

Do not stop corticosteroids prematurely, as seizures peak during days 11-21 when inflammation from dying parasites is maximal. 3 The conventional 10-day steroid course is insufficient and results in significantly more seizures compared to the 28-day enhanced regimen. 4