Topiramate

Aka: Topiramate, Topamax, Eprontia, Qudexy XR, Trokendi XR

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II. Indications

  1. Seizure Disorder
    1. Simple Partial Seizures
    2. Complex Partial Seizures
    3. Generalized Tonic Clonic Seizures
  2. Non-Seizure Related Indications
    1. Migraine Prophylaxis
    2. Obesity Management
    3. Essential Tremor
    4. Bipolar Disorder
    5. Alcohol Dependence

III. Dosing: Seizures

  1. Adult (age >10 years old) - Standard Release
    1. Initial: 25 mg orally twice daily (consider starting 25 mg only at bedtime)
    2. Increase by 25-50 mg/day increments per week
      1. Week 2: 50 mg orally twice daily
      2. Week 3: 75 mg orally twice daily
      3. Week 4: 100 mg orally twice daily
      4. Week 5: 150 mg orally twice daily
      5. Week 6: 200 mg orally twice daily
    3. Target
      1. Adults: 400 mg/day divided twice daily
      2. Elderly: 200 mg/day divided twice daily
    4. Maximum dose: 1600 mg/day divided twice daily
      1. However, doses above 400 mg/day have not been shown to be more effective
  2. Child (age 2 to 10 years, weight based protocol) - Standard Release
    1. Initial: 1-3 mg/kg up to 25 mg orally at bedtime for 1 week
    2. Increase by 1-3 mg/kg/day to 25 to 50 mg increments per week
    3. Target range: 5-9 mg/kg/day divided twice daily
      1. Weight <11 kg: Target 75 to 125 mg orally twice daily
      2. Weight 12 to 22 kg: Target 100 to 150 mg orally twice daily
      3. Weight 23 to 31 kg: Target 100 to 175 mg orally twice daily
      4. Weight 32 to 38 kg: Target 125 to 175 mg orally twice daily
      5. Weight >38 kg: Target 125 to 200 mg orally twice daily
  3. Extended Release (Trokendi XR or Qudexy XR)
    1. Trokendi XR is approved for age >6 years
    2. Qudexy XR is approved for age >2 years
    3. Use same dosing as above, but dose daily instead of twice daily

IV. Dosing: Migraine Prophylaxis - Adult (and child age >12 years old)

  1. Standard Release
    1. Start 25 mg orally at bedtime
    2. Titrate weekly, starting at increase of 25 mg/day/week
      1. Week 2: Take 25 mg orally twice daily
      2. Week 3: Take 25 mg orally in am and 50 mg orally in pm
      3. Then 50 mg orally twice daily
  2. Extended Release (Trokendi XR or Qudexy XR)
    1. Use same dosing as above, but dose daily instead of twice daily

V. Dosing: Other Indications - Adults (not FDA approved)

  1. Essential Tremor
    1. Start 25 mg orally daily
    2. Titrate by increasing 25 mg/day/week
    3. Target: 100 mg/day divided twice daily
    4. Maximum: 400 mg/day
  2. Bipolar Disorder
    1. Start 25 to 50 mg orally daily
    2. Titrate to effective target dose
    3. Maximum: 400 mg/day
  3. Alcohol Dependence
    1. Start 25 mg orally daily
    2. Titrate by increasing 25 mg/day/week
    3. Target: 300 mg/day divided twice daily
    4. Limit duration to 14 weeks
  4. Obesity Management
    1. See Phentermine and Topiramate (Qsymia)

VI. Safety

  1. Pregnancy Category D
    1. Associated with fetal malformations (esp. Cleft Lip and Palate)
    2. No increase in Autism risk (in contrast to Valproate)
      1. Hernandez-Diaz (2024) N Engl J Med 390(12):1069-79 +PMID: 38507750 [PubMed]
  2. Unknown Safety in Lactation

VII. Adverse Effects

  1. Common (Dose related)
    1. Interferes with concentration and memory
      1. Refered to pejoratively by some as "Dopamax"
    2. Confusion
    3. Sedation
    4. Lethargy
    5. Dizziness
    6. Ataxia
    7. Diplopia
    8. Tremor
    9. Nervousness or Anxiety
    10. Fatigue
    11. Depression
    12. Emotional Lability
    13. Anorexia and weight loss
    14. Dyspepsia
  2. Serious
    1. Nephrolithiasis
      1. Secondary to carbonic anhydrase inhibition
    2. Narrow Angle Glaucoma
    3. Hyperammonemia with Encephalopathy
      1. Increased risk when used with Valproic Acid
    4. Hypothermia
      1. Increased risk when used with Valproic Acid
    5. Hypohidrosis and Heat Stroke risk
      1. Increased risk in children, and when combined with Anticholinergic Medications
  3. Other
    1. Hyperchloremic Non-Anion Gap Metabolic Acidosis

VIII. Metabolism

  1. Excreted unchanged in the urine
  2. Adjust dose if Creatinine Clearance <60 ml/min/sec
    1. Decrease dose to 50%
  3. Following Hemodialysis
    1. Consider replacement dose after Hemodialysis

IX. Drug Interactions

  1. Alcohol
    1. Avoid Alcohol within 6 hours of Trokendi XR (decreases Topiramate release)
  2. CNS Depressants
    1. Potentiates CNS depression
  3. Lithium
    1. Increases Lithium levels
  4. Digoxin
    1. Increases Digoxin levels
  5. Oral Contraceptives
    1. Decreases contraceptive efficacy

X. Resources

  1. Topiramate tablets and capsules (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=21628112-0c47-11df-95b3-498d55d89593

XI. References

  1. (2022) Presc Lett, Resource #361206, Antiseizure Medications
  2. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 56-7
  3. Hamilton (2020) Tarascon Pocket Pharmacopoeia

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Related Studies

Cost: Medications

topiramate (on 8/23/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
TOPIRAMATE 100 MG TABLET Generic $0.06 each
TOPIRAMATE 15 MG SPRINKLE CAP Generic $0.60 each
TOPIRAMATE 200 MG TABLET Generic $0.10 each
TOPIRAMATE 25 MG SPRINKLE CAP Generic $0.69 each
TOPIRAMATE 25 MG TABLET Generic $0.04 each
TOPIRAMATE 50 MG TABLET Generic $0.04 each
TOPIRAMATE ER 100 MG CAPSULE Generic $25.38 each
TOPIRAMATE ER 150 MG CAPSULE Generic $16.07 each
TOPIRAMATE ER 200 MG CAPSULE Generic $33.83 each
TOPIRAMATE ER 25 MG CAPSULE Generic $9.33 each
TOPIRAMATE ER 50 MG CAPSULE Generic $11.61 each
topamax (on 6/22/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
TOPAMAX 100 MG TABLET Generic $0.06 each
TOPAMAX 200 MG TABLET Generic $0.10 each
TOPAMAX 25 MG TABLET Generic $0.04 each
TOPAMAX 50 MG TABLET Generic $0.04 each
eprontia (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
EPRONTIA 25 MG/ML SOLUTION $1.48 per ml
trokendi xr (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
TROKENDI XR 100 MG CAPSULE $28.78 each
TROKENDI XR 200 MG CAPSULE $39.22 each
TROKENDI XR 25 MG CAPSULE $11.10 each
TROKENDI XR 50 MG CAPSULE $14.48 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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