topiramate

Adjunctive therapy

Brands: Topamax, Trokendi XR, Qudexy XR

Last reviewed 2025-12-30

Reviewed by PsychMed Editorial Team.

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Quick answers

What is topiramate?
Topiramate (brand Topamax; generics) is an antiepileptic medication and migraine-preventive agent. In psychiatry it is used off label in select cases for alcohol use disorder, binge-eating disorder, and as a weight mitigation strategy when antipsychotic-associated weight gain is a limiting factor (label/clinical).
What is Topamax?
Topamax is a brand name for topiramate (other brands: Trokendi XR, Qudexy XR).
What is Topamax (topiramate) used for?
Label indications include: Epilepsy; migraine prophylaxis (label). Common off-label use includes alcohol use disorder and weight mitigation (clinical).
What drug class is Topamax (topiramate)?
Broad-mechanism antiepileptic and migraine-preventive agent (includes voltage-gated sodium-channel effects, enhanced GABA activity, AMPA/kainate antagonism, and carbonic anhydrase inhibition). In psychiatry it is sometimes used off label for alcohol use disorder, binge-eating disorder, and to mitigate antipsychotic-associated weight gain, balancing potential benefit against cognitive and metabolic adverse effects.
What strengths does Topamax (topiramate) come in?
Immediate-release tablets: 25 mg, 50 mg, 100 mg, 200 mg; sprinkle capsules exist (label/manufacturer-dependent).

Snapshot

Primary label indications include: Epilepsy; migraine prophylaxis (label).
Class: Adjunctive therapy
Common US brands: Topamax, Trokendi XR, Qudexy XR
Therapeutic drug monitoring not routinely recommended.
Last reviewed: 2025-12-30

Label indications

Epilepsy; migraine prophylaxis (label). Common off-label use includes alcohol use disorder and weight mitigation (clinical).

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Clinical Highlights

Topiramate (brand Topamax; generics) is an antiepileptic medication and migraine-preventive agent. In psychiatry it is used off label in select cases for alcohol use disorder, binge-eating disorder, and as a weight mitigation strategy when antipsychotic-associated weight gain is a limiting factor (label/clinical). The main tradeoff is tolerability: cognitive slowing (“word-finding” difficulty), paresthesias, and fatigue are common reasons for stopping, especially when titrated quickly (label/clinical).

Topiramate is associated with metabolic acidosis and kidney stones in susceptible patients because it is a carbonic anhydrase inhibitor; risk assessment often includes renal history, hydration, and baseline bicarbonate when clinically indicated (label/clinical).
Pregnancy risk matters: topiramate is linked to fetal harm, and higher-dose use can reduce effectiveness of estrogen-containing oral contraceptives; shared decision-making often includes contraception and pregnancy-intent screening (label).
The compare view, topiramate evidence feed, and topiramate print page support review of off-label use goals alongside safety monitoring.

Dosing & Formulations

Immediate-release tablets: 25 mg, 50 mg, 100 mg, 200 mg; sprinkle capsules exist; extended-release products (e.g., Trokendi XR, Qudexy XR) are distinct formulations (label/manufacturer-dependent). Psychiatric off-label use generally starts low (often 25 mg nightly) and increases in weekly steps to reduce cognitive and paresthesia burden (clinical).

Target doses depend on the goal: migraine prevention often uses ~100 mg/day; alcohol-use-disorder trials titrated up to higher doses (e.g., 300 mg/day in Johnson 2007), while weight-mitigation strategies often use lower to moderate doses limited by tolerability (label/clinical).
Renal impairment reduces clearance; dose adjustment is common when kidney function is reduced (label).

Monitoring & Risks

Neurocognitive adverse effects (slowed thinking, attention problems, word-finding difficulty) are common; reassessment focuses on functional impact at school/work and driving safety when sedation is present (label/clinical). Metabolic acidosis and kidney stones: monitor for symptoms and consider serum bicarbonate in higher-risk situations, especially when other acidosis-promoting therapies are present (label/clinical).

Ocular warning: acute myopia and secondary angle-closure glaucoma are rare but urgent; new eye pain or sudden vision changes require prompt evaluation (label).
Class warning: antiepileptic drugs have been associated with suicidal thoughts/behaviors; mood and safety monitoring is appropriate when risk is elevated (label/class).

Drug Interactions

Enzyme-inducing antiepileptics (e.g., carbamazepine, phenytoin) can lower topiramate exposure; dosing may need adjustment when these are started or stopped (label). Topiramate can reduce estrogen exposure from some oral contraceptives at higher doses; consider backup contraception when pregnancy risk is relevant (label).

Topiramate can increase hyperammonemia risk when combined with valproate and can worsen metabolic acidosis when combined with other carbonic anhydrase inhibitors or metformin; regimen review focuses on total metabolic burden (label/clinical).

Practice Notes

For alcohol use disorder, evidence supports topiramate as one effective option, but benefit depends on adherence and tolerability; slow titration and early side-effect follow-up improve persistence (Johnson 2007/clinical). When used to mitigate antipsychotic-associated weight gain, framing often includes the option of switching to a lower metabolic-risk antipsychotic and strengthening lifestyle interventions in parallel (Ellinger 2010/clinical).

If cognitive adverse effects limit function, dose reduction, slower titration, or discontinuation are common next steps rather than “pushing through,” because impairment can persist while on drug (clinical).

References

Topiramate tablets prescribing information — DailyMed (2025)
Topiramate for Treating Alcohol Dependence A Randomized Controlled Trial — JAMA (2007)
Double Blind, Randomized, Placebo Controlled Trial OF Topiramate Plus Cognitive Behavior Therapy IN Binge Eating Disorder — Journal of Clinical Psychiatry (2007)
Efficacy OF Metformin AND Topiramate IN Prevention AND Treatment OF Second Generation Antipsychotic–induced Weight Gain — The Annals of Pharmacotherapy (2010)
AGNP Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology — Pharmacopsychiatry (2018)