Topiramate is a medication to help treat alcohol use disorder. It works by both reducing cravings and lessening withdrawal symptoms. It is not yet FDA approved for this purpose but will likely at least be approved as an adjunct treatment in the future, and many clinicians who treat AUD are using it, albeit, off label, to aid people in their recovery.
What Is Topiramate?
Topiramate is an anticonvulsant (anti-seizure) medication that is most commonly used to treat certain seizures, migraine headaches, and some types of refractory depression and mental health disorders.[1]
It comes in many forms, all oral, including a tablet, sprinkle capsule, long-acting capsule, and a solution. Sprinkle capsules and extended-release capsules are taken with food.
Evidence For Use in AUD Treatment
While there are several FDA approved medications for AUD including Naltrexone, Acamprosate, and Disulfiram, many clinicians are starting to use Topiramate either in conjunction with these other medications, or by itself in patients who do not respond or cannot otherwise have one of these other medications.
Topiramate reduces a person’s alcohol dependence, promotes abstinence, and reduces the harmful psychosocial consequences of drinking. An early 2006 study showed Topiramate can reduce the overall harms for a person with AUD.[2]
A later 2011 study seems to support these findings, where an open-label controlled study was conducted and found low-dose topiramate worked well as an adjunct psychotherapeutic treatment for AUD.[3] The study found the drug to be “well tolerated and effective” at reducing alcohol cravings and helping with symptoms of depression and anxiety associated with withdrawal. Note that this was described as an adjunct treatment, meaning it should be combined with a different primary treatment for the best effect, at least in this study.
More recently, A 2021 study helped reinforce the previous findings of the studies already discussed, again showing the drug has promise in the treatment of AUD.[4]
As of right now, topiramate is not FDA approved for use in the treatment of AUD and has still been under-researched, considering the fairly promising studies on how it may help treat the condition.
How Topiramate Works for AUD
Exactly why topiramate works as an AUD treatment is not fully understood, although it’s been proposed that it has to do with the way it changes certain reward systems in the brain. In essence, it’s believed the drug reduces the sense of reward a person feels when ingesting alcohol while also helping to reduce the withdrawal symptoms a person experiences if they don’t drink. With that said, more research is needed into how this medication affects the brain and why it seems effective as an adjunct AUD treatment.
Who Is a Candidate For Topiramate?
Almost everyone. Topiramate has a few side effects (discussed more below) but very few “contraindications”, meaning reasons a person should absolutely not take the drug. In addition, because topiramate has mostly been study as an adjunctive medication, taking in conjunction with the other FDA approved medications for alcohol use disorder - it should probably be given along with these other medications, although it could be given by itself if patients have not had success with, or have not otherwise tolerated, the other FDA medications for AUD.
Side Effects & Risks
Topiramate is generally safe and well tolerated, but their are some side effects. Common side effects include dizziness and what is sometimes referred to as “brain fog” where a person can feel mentally foggy. Known side effects of topiramate include decreased appetite and some weight loss (which can be a benefit for individuals who are also overweight or trying to lose weight. Additional, less common side effects include the following:
- Back, bone, and muscle pain
- Changes in the ability to taste
- Changes to menstruation patterns
- Unusual bleeding and bruising
- Constipation
- Dry mouth
- Headache
- Drowsiness
- Numbness, burning, or tingling at the hands and feet
- Teary or dry eyes
- Weight loss
- Nervousness
Again, topiramate is not FDA approved for treating AUD. Its use for this purpose still requires more research. However, many clinicians do use it frequently for many conditions, including “off label” to treat AUD. Current research seems to suggest it is a safe and effective AUD treatment.
Topiramate for AUD FAQs
What is the most effective treatment for alcohol dependence?
There are 3 FDA approved treatments for AUD that are still considered the gold standard medications - Naltrexone, Acamprosate, and occasionally although less commonly these days, Disulfiram. However, other medications are also often used “off label” to treat AUD, including Topiramate.
Do most patients with AUD use medications?
Unfortunately, no. The truth is that, while good medications exist to help treat AUD, they are woefully under prescribed. One study reported only about 1.6% of patients with likely AUD use medications. The reasons for this are probably multifactorial, but include screening for AUD among providers and inadequate counseling of patients about the availability of MAT for AUD. The fact that so few people are receiving these approved medications is regarded as an urgent issue. More needs to be done to improve the ability of patients to get treatments that are proven to help them combat alcohol dependence.[6]
How does topiramate work for AUD?
It’s not entirely known the mechanism by which Topiramate treats AUD. It’s theorized that topiramate works on the brain’s reward system, altering the amount of dopamine that is released when a person’s drinks alcohol or encounters triggers to drink. More work needs to be done to understand the exact mechanism by which Topiramate works to treat AUD.
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