Topiramate (Topamax)

Anticonvulsant (GABA, glutamate facilitation of GABA transmission, receptor antagonist on AMPA and KA)

  • PTSD3 (especially with alcohol)
  • Bulimia2
  • Antipsychotic weight loss2
  • Schizophrenia: Augmentation (including clozapine) for positive and negative symptoms1
  • Methamphetamine1, amphetamine1, cocaine2, alcohol2, gambling2
  • Irritability (eg, in borderline)2
  • OCD3
  • Migraine prevention1

Features

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Handout

Dosing

50-200mg/d, raise slowly (by 25mg/wk) to prevent cognitive side effects. Up to 600mg/d in binge eating.

Also available as XR.

LABS: Check annual serum bicarbonate (metabolic acidosis risk).

INTERACTIONS: Strongly speeds up (induces) 2C19 and 3A4 at doses ≥ 200 mg (lowering birth control). Carbamazepine lowers topiramate levels 50%.

Management

Consistently improves impulsivity and irritability, but otherwise has paradoxical effects where it may worsen conditions it usually improves, like psychosis and mood (Mowla A et al,Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(4):970-973).

Protects against neurotoxicity from meth/amphetamine/cocaine abuse.

TOLERABILITY: Dizzy, imbalance, cognitive impairment.

RISKS: Rare renal stones, hyperammonemia, visual field deficits, osteopenia, hyperthermia, metabolic acidosis, bicarbonate is recommended. Worsens secondary angle closure glaucoma.

EMR Text

PTSD

Topiramate use based on multiple randomized controlled trials in PTSD, including civilian, military, and treatment-resistant populations (Yeh MS et al, CNS Neurosci Ther. 2011;17(5):305-310).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Schizophrenia

Topiramate use based on multiple randomized controlled trials in schizophrenia, where it augmented antipsychotics (including clozapine) and improved negative and positive symptoms (Zheng W et al, Acta Psychiatr Scand. 2016;134(5):385-398).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Weight loss

Topiramate use based on multiple randomized controlled trials in obesity and for weight loss on psychotropics (Correll CU et al, J Clin Psychiatry. 2016;77(6):e746-e756).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Borderline Personality

Topiramate use based on multiple randomized controlled trials in borderline personality disorder (Nickel M, Eur Arch Psychiatry Clin Neurosci. 2007;257(7):432-433).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

OCD

Topiramate use based on multiple randomized controlled trials in OCD, including trials in OCD with bipolar disorder (Berlin HA et al, J Clin Psychiatry. 2011;72(5):716-721; Sahraian A et al, J Affect Disord. 2014;166:201-205).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Binge eating and bulimia

Topiramate use based on multiple randomized controlled trials in compulsive gambling (de Brito AM et al, J Gambl Stud. 2017;33(1):249-263).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Binge eating and bulimia

Topiramate use based on multiple randomized controlled trials in binge eating and bulimia (Nourredine M et al, CNS Spectr. 2021;26(5):459-467; Arbaizar B et al, Gen Hosp Psychiatry. 2008;30(5):471-475).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Alcohol use disorder

Topiramate use based on multiple randomized controlled trials in alcohol use disorder, where it reduced cravings and drinking days (Fluyau D et al, J Psychopharmacol. 2023;37(2):155-163).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

Methamphetamine, stimulants, and cocaine

Topiramate use based on multiple randomized controlled trials where it reduces cravings and promoted abstinence in methamphteamine, amphetamine, and cocaine use disorders. Topiramate also protects against neurotoxicity from these substances (Rezaei F et al, Fundam Clin Pharmacol. 2016;30(3):282-289; Prince V and Bowling KC, Am J Health Syst Pharm. 2018;75(1):e13-e22).

Topiramate side effects, including cognitive, renal stones, and visual risks, reviewed with patient.

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