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    Anticonvulsant Prophylaxis and Steroid Use in Adults With Metastatic Brain Tumors (beta)

    Based on guidelines from the Congress of Neurological Surgeons, also endorsed by ASCO and SNO.

    Evidence
    Level 1
    Level 2
    Level 3
    N/A

    Anticonvulsants

    Antiepileptic Drugs
    1. Prophylactic antiepileptic drugs are not recommended for routine use in patients with brain metastases who did not undergo surgical resection and who are otherwise seizure free.
    2. Routine postcraniotomy antiepileptic drug use for seizure-free patients with brain metastases is not recommended.

    Steroid Therapy vs No Steroid Therapy

    Steroid Therapy vs No Steroid Therapy
    1. For asymptomatic brain metastases patients without mass effect, insufficient evidence exists to make a treatment recommendation for this clinical scenario.
    2. For brain metastases patients with mild symptoms related to mass effect, corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of dexamethasone 4 to 8 mg/day be considered.
    3. For brain metastases patients with moderate to severe symptoms related to mass effect, corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms that are consistent with increased intracranial pressure, it is recommended that higher doses, such as 16 mg/day or more, be considered.
    Choice of Steroid
    1. If corticosteroids are administered, dexamethasone is the best drug choice given the available evidence.
    Duration of Corticosteroid Administration
    1. Corticosteroids, if administered, should be tapered as rapidly as possible, but no faster than clinically tolerated, on the basis of an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy.
    Dosing
    1. The Panel’s expert opinion is that, given the important adverse effects of steroids, the minimum effective dose (often no more than 4 mg) should be used where possible and night-time doses of steroids should be avoided to minimize toxicity.
    What do the icons mean?  
    Research PaperChang SM, Messersmith H, Ahluwalia M, et al. Anticonvulsant Prophylaxis and Steroid Use in Adults With Metastatic Brain Tumors: ASCO and SNO Endorsement of the Congress of Neurological Surgeons Guidelines. J Clin Oncol. 2019;37(13):1130-1135.