Warning:The primary use of Topiramate, and the only use for which it has regulatory approval, is to treat seizures. Some people use Topiramate to treat other conditions, which may include PTSD, Axis II mood disorders, and eating disorders. However, no peer-reviewed studies have established that Topiramate is safe and effective for those conditions, and therefore these uses have not been approved by the FDA. There is limited evidence supporting these uses that comes from small-scale case studies, but as yet there have been no large studies that researchers have published.


What is Topiramate?

Topiramate is often sold under the brand name Topamax. It is an anti-convulsive drug that stands apart from all other drugs used to treat convulsions or mood disorders because it does not share the same chemical composition. Medical researchers currently do not know how Topiramate works.


When did the FDA approve this drug for marketing in the US, and what uses of the drug are approved?

The FDA gave final approval for the drug on December 24, 1996. As stated above, the only approved use to date is the treatment of convulsions.


Does Topiramate have a generic version?

The manufacturer of Topiramate still holds patent protection over the drug, so there is no generic version available yet.


How is Topiramate different from other mood stabilizers?

There are two things that set Topiramate apart from other drugs in this class. First of all, physicians and psychiatrists sometimes prescribe it when other mood-stabilizing drugs fail to be effective for a patient. Secondly, the set of side effects that patients may experience is quite different on Topiramate compared to other mood stabilizers.


How is Topiramate different from carbamazepine and valproate?

For rapid cycling or mixed bipolar states, there are some cases where Topiramate is effective when these other two drugs are not.


Which disorders has Topiramate been most successful in controlling so far?

The lack of research about Topiramate makes it hard to tell which disorders will respond best to the drug: to date, there is not enough psychiatric research to make specific recommendations. In the field, practitioners have had success when prescribing Topiramate to individuals with bipolar disorders that have resisted other forms of treatment. The most effective use of Topiramate appears to be the case of patients whose use of lamotrigine has induced mania. Some psychiatrists have reported using Topiramate to help relieve the symptoms of PTSD and the side effects related to eating that other psychiatric drugs can create.


Can Topiramate treat episodes of depression, mania, and mixed states? Can it prevent these episodes?

While Topiramate’s first use was for the treatment of mania, depression, or mixed states that were resistant to other drugs, its effectiveness for preventing those states has not yet been tested. There have been no research studies that placed patients on Topiramate for an extended time and evaluated whether it decreased their likelihood of these episodes.


What lab tests are necessary before a patient can be prescribed Topiramate?

It is important to test for any of several conditions that can interact with mood disorders. The necessary tests include blood and urine tests, because these conditions could be the cause of a mood disorder.


What dosage is appropriate for starting a course of Topiramate?

The initial dose for Topiramate should be either 12.5 or 25 milligrams taken either once or twice a day. This dose increases by 12.5 or 12 milligrams each week until it reaches the final level, which depends on the use of the drug and how the patient is responding. A typical final dosage is between 100 and 200 mg per day, although some patients benefit from no more than 50 mg. The case of PTSD entails a final dose of approximately 175 mg per day and generally not exceeding 500 mg per day.


Are there any special problems prescribing Topiramate for
people taking lithium, carbamazepine (Tegretol), or valproate (Depakene, Depakote)?

There are no known interactions between Topiramate and lithium. However, carbamazepine can lower the blood-plasma level of Topiramate by 50 percent and valproate can lower it by 15 percent. Topiramate itself can lower the blood-plasma level of valproate by 10 percent. Thus far, there are no known interactions for patients taking Topiramate and either lamotrigine or gabapentin.


What final doses of Topiramate are typical and what doses are appropriate for different disorders?

The final doses of Topiramate vary widely based on the targeted disorder, the patient, and whether or not the patient is taking any other drugs at the same time. The most common doses fall between 50 and 200 mg a day for most therapies, but this can be lower for PTSD. Higher final doses may be required if Topiramate is being taken alone, up to 500 mg a day. Some patients experience relief with only 25 mg a day.


How long until the patient feels the effects of Topiramate?

This also varies significantly depending on the individual. Some feel the effects within days, while others need up to a month before they feel any difference.


What is the side effect profile of Topiramate?

Topiramate’s side effects appear most strongly just after an increase in dosage. A research study that compared 711 participants taking Topiramate and 419 taking a placebo observed the following sets of side effects in both groups:
Common Adverse Reactions (%)

(Topiramate = 200 mg/day)
Adverse Reaction Topiramate Placebo

Somnolence 30% versus 10% Placebo

Dizziness 28% versus 14% Placebo

Vision problems 28% versus 9% Placebo

Unsteadiness 21% versus 7% Placebo

Speech problems 17% versus 3% Placebo

Psychomotor slowing 17% versus 2% Placebo

Pins and needles 15% versus 3% Placebo

Nervousness 16% versus 8% Placebo

Nausea 12% versus 6% Placebo

Memory problems 12% versus 3% Placebo

Tremor 11% versus 6% Placebo

Confusion 10% versus 6% Placebo


Which of these side effects are the strongest?

The five side effects that were most likely to cause people to discontinue use of Topiramate were psychomotor slowing, fatigue, memory problems, confusion, and somnolence. In rare cases, approximately one person of patients develop kidney stones and a very few develop acute glaucoma.


What psychiatric side effects do people who take Topiramate experience?

The list includes sedation, psychomotor slowing, agitation, anxiety, concentration problems, forgetfulness, confusion, depression, and depersonalization. There are also rare cases of psychosis.


How does Topiramate interact with prescription and
over-the-counter medications?

The interactions between Topiramate, valproate, and carbamazepine have already been noted above. In addition to that, Topiramate appears to raise the blood-plasma level of phenytoin, while phenytoin decreases the level of Topiramate by 50 percent. There have been some reports that Topiramate reduces the effectiveness of oral contraceptive pills.


Is it safe to take Topiramate and drink alcohol?

If you drink while taking Topiramate, then you may experience more intense side effects.


Is it safe to take Topiramate if you are pregnant?

The FDA places Topiramate in the “C” category for pregnancy safety. That means the drug is known to affect the human fetus in an adverse way, but there is not much research about the specifics, and that the drugs benefits may outweigh the risks.


Is it safe for children and teens to take Topiramate?

Yes, the FDA has approved the drug for children.


Is it safe for older adults to take Topiramate?

So far, there are no reports about using Topiramate for older adults, although there is no reason to believe that they would have a different response to it.


Is it necessary to wean off Topiramate?

There are no reports of bad reactions to suddenly stopping use of Topiramate, so there is no need to wean off the drug. On the other hand, the entire class of anticonvulsants is known to lead to seizures if you stop taking them suddenly. Therefore, the only thing that should lead to a sudden cessation of Topiramate use is the rise of a dangerous side-effect.


Is it possible to overdose on Topiramate?

There are no reported effects and no deaths from an overdose of Topiramate.


Does Topiramate interact poorly with MAOIs?

There is no danger in taking Topiramate with MAOIs.


Is Topiramate expensive?

When bought in bulk, Topiramate is not particularly expensive. The 25 mg per pill set costs about $1.45 a pill, 100 mg costs $3.75 a pill, and 200 mg costs about $5.75 a pill.


Can Topiramate help people who have not found relief with other psychopharmacologics?

That is precisely the role of Topiramate. It is effective for those who found no useful effect from other mood stabilizers. Potential new uses of the drug include PTSD and reducing alcohol cravings, as well as heading off migraine headaches.


Why use Topiramate?

Topiramate is most useful for people who have bipolar mood disorders that other mood stabilizers have been unable to control. It can relieve symptoms and make taking antidepressants possible for people who ere unable to take them before without experiencing mania or a mixed state. Topiramate has a favorable side effect profile and up to half of all people who take the drug experience weight loss. This is a beneficial counteraction to the weight gain that many antidepressants can cause.


Does Topiramate have downsides?

Because the drug is only about 20 years old, there has not been much study about prolonged use, especially with regards to side effects. There has not been enough time to determine how long the benefits of Topiramate last and if they end or reduce after sufficient time. Likewise, much of the drug’s use as a mood stabilizer and for disorders like PTSD is currently not supported by a large body of research, pending more publications.


If Topiramate has so little evidence supporting its use, why should anyone prescribe it over an older drug that has more research showing its effectiveness?

First of all, Topiramate generally has a better side effect profile than those older drugs. Some patients find that older mood stabilizers have side effects that are too dangerous or impact their lives too much.
Second of all, many patients find that the older drugs do not control their disorders, while Topiramate does. That makes it the only effective known remedy for them.
Lastly, topirmate is so far the only psychopharmacologic agent that appears to have an effect in providing relief for PTSD symptoms. These symptoms can be extremely debilitating.


Is Topiramate prescribed all over the world?

Yes, many nations have approved Topiramate for use and prescribe it.