Topiramate Is Not Recommended for Cannabis Use Disorder

Pharmacologic Recommendations

First‑Line Behavioral Interventions

Alternative Pharmacologic Options

Topiramate for Addiction

Primary Indication: Alcohol Use Disorder

• The American Association for the Study of Liver Diseases recommends topiramate as a second-line pharmacotherapy for reducing heavy drinking in alcohol use disorder, with doses of 200-300 mg/day showing the strongest evidence for decreasing drinking days and heavy drinking episodes 4
• Topiramate represents the most promising pharmacotherapy among anticonvulsants for alcohol use disorder specifically targeting drinking reduction (not abstinence) 4
• Topiramate reduces heavy drinking days and total alcohol consumption in patients with alcohol use disorder 4
• Topiramate may decrease liver enzyme levels in patients with alcohol-related liver disease 4

Secondary Indications with Moderate Evidence

• The American Gastroenterological Association suggests that topiramate has potential for reducing cocaine use days, although evidence is weaker than for alcohol 5, 6, 7
• Topiramate reduces binge eating episodes and promotes weight loss in patients with binge eating disorder, and is FDA-approved as phentermine-topiramate combination for obesity 5, 6, 7

Critical Safety Monitoring

• The American College of Gastroenterology recommends periodic monitoring of serum bicarbonate levels due to the risk of metabolic acidosis caused by topiramate 8, 9
• Monthly pregnancy tests are necessary in women of childbearing age due to the high teratogenicity of topiramate 5, 6, 7, 9
• Blood pressure and heart rate should be monitored in patients using the phentermine-topiramate combination 5, 6, 7
• Kidney function should be monitored in patients with nephrolithiasis risk 9

Absolute Contraindications

• Pregnancy or inadequate contraception in women of childbearing potential is an absolute contraindication for topiramate due to its high teratogenicity 5, 6, 7, 9
• History of kidney stones, untreated closed-angle glaucoma, and significant cognitive impairment are relative or absolute contraindications for topiramate 9

Discontinuation Protocol

• The American Academy of Neurology recommends that topiramate should never be stopped abruptly due to seizure risk, and should be tapered by taking one capsule every other day for at least 1 week before complete cessation 6, 7, 8