Topamax, a brand name for Topiramate, is also known as Topamax. It can be taken orally as an immediate-release or extended-release medicine.

Topiramate is used:

• Migraine:

  • It is used to prevent migraine headaches in patients aged 12 and over.

• Seizures

  • It can be used as a single or combination therapy to control seizures.

• Adults can use topiramate off-label

  • Weight gain induced by antipsychotics
  • Binge eating disorder
  • Cluster Headache Prevention
  • Preventing short-term unilateral neuralgiform headache attacks
  • Essential tremors

 

Topamax (Topiramate) Dose in Adults

Topamax dosage in the treatment of Binge-eating Disorder as an Alternative Agent (Off-label).

• Initial dose: 25 mg once daily. Gradually increase the dosage to 25-100 mg every other week. This will depend on your response and tolerance. You can take 400 mg/day.

Topamax (Topiramate), Dosage in the prevention or treatment of cluster headaches (alternative agent; adjunctive medicine):

• Initial dose: 25-50mg once daily. Gradually increase the dose in increments of 25-50mg every other week based on response. The recommended daily dose is 100-200mg/day.
• It can be combined with verapamil.

Topamax (topiramate), Dose to prevent short-lasting unilateral neuralgiform migraine attacks (alternative agent).

• Initial: 15–25 mg once every day. Depending on the response and tolerability, the dose could be increased.

Topamax (Topiramate), Dosage in Migraine Prevention

• Initial dose: Daily dose of 25 mg. Depending on how you react and how well you tolerate it, increase the dose by 25 to 50 mg every other week.

Topamax (Topiramate), Dosage in the Treatment of Seizures

• Monotherapy

  • Initial dose: 50 mg every hour, with weekly dose increases of 50 mg based on response and tolerance increasing the amount up to 200 mg each day. After that, you can go up to 400 mg per day by adding 100 mg increments each week.

• Adjunctive therapy:

  • Initial: 25-50 mg per oral daily; increasing in 25-50 mg increments weekly based on response. The maximum daily intake is 400 mg.

Dosage of Topamax (topiramate), for essential tremors (alternate drug):

• Initial: 25 mg oral O.D. or b.i.d. daily; gradually increase the dose in increments of 25-50 mg at intervals >=1week based on response.

Dosage of Topamax (topiramate): Antipsychotic-induced weight gain (alternative agent).

• Initial: 50 mg per orally per day; gradually increase to 25 to 50 mg every other week based on response and tolerance, up to a maximum of 200 mg/day.

Topamax (topiramate). Dosing conversion

• There are two types of immediate-release formulations:

  • You can convert the same daily total dose, but change the frequency of immediate-release (2x daily) or extended (once daily).

• Between ER formulations

  • Trokendi XR has not shown bioequivalence with Qudexy XR.

• Stopping therapy

  • To prevent seizure potential or withdrawal symptoms, you should gradually withdraw topiramate over several weeks to several months if you are receiving long-term treatment.

Topamax (Topiramate) Dose in Children

Notice: To avoid rebound effects, the dosage should be slowly reduced.

Topamax (Topiramate), for infantile spasms treatment:

Infantile spasm newly-diagnosed:

• Dosing per weight:

  • Children and infants 3-24 months

    • Release immediately:

      • Initial: 1 to 2 mg/kg oral per day; continue to titrate every 3-7 days in 1 to 3-mg/kg/day increments until seizures are controlled
      • Reported mean dose range: 9.1-14 mg/kg/day
      • Reported range: 4 to 27 mg/kg/day

• Refractory: Fixed dosing

  • Infants >=3 Months to Children =4 Years; Weight >=7 Kg:

    • Instant-release

      • Initial: Daily dose of 25 mg. until seizures are under control, titrate in 25 mg/day increments every two to three days.
      • Maximum daily dose 24 mg/kg/day

Topamax (Topiramate) as an adjunctive treatment for seizures:

Children and adolescents 2-16 years old

• Partial onset seizures, or Lennox–Gastaut syndrome

  • Release immediately:

  • Initial: 1 to 3 mg/kg oral daily
  • The highest dose is 25 mg/dose, given twice daily in increments of 1 or 3 mg/kg/day for a maximum of one to two weeks once a week. Titrate based on the outcome
  • In 2 doses, the maintenance dose is usually 5 to 9 mg/kg/day

  • Extended-releaseQudexyXR:

  • Initial: 25mg per oral once daily (approximately 1-to-3 mg/kg/day) taken once a night for one week. Then, increase in increments of 1-to-2 weeks at 1 to-3 mg/kg/day. Round to the closest appropriate capsule size and administered once daily.
  • Response to Titrate Dosage
  • The maintenance dose is usually 5 to 9mg/kg once daily. (range: 5-9 mg/kg/dose one time daily).

  • Extended-releaseTrokendi:

  • Initial: 25 mg once daily, administered by mouth once daily for approximately 1 to 2 weeks. Then, increase in 1- to 2-week intervals at 1 to 3, mg/kg/day increments. Each day, take 1 to 3 mg/kg/day and round to the next appropriate capsule size.
  • Maintenance: 5 to 9 mg/kg once daily

• Primary generalized tonic-clonic seizures

  • Instant-release

    • Initial: 1 to 3mg/kg per orally per day (maximum dosage: 25 mg/dose). Nightly for one week.
    • Increase the dose to 6 mg/kg/day with 2 divided doses in increments of 1 to 3 mg/kg/day.

  • Extended-releaseQudexyXR:

    • Initial: 25mg per oral once daily (approximately 1- to 3 mg/kg/day), taken once a night for one week. Then, increase in 8 weeks by increasing the dose by 1 to 3. mg/kg/day. Round to the closest capsule size and you will reach a target dose at 6 mg/kg/day.

  • Extended-releaseTrokendi:

    • Initial: 25mg once daily (approximately 1 - 3 mg/kg/day) taken once daily for one week. Then, increase in 8 weeks by increasing the dose in increments (1 to 3 mg/kg/day). Round to the closest capsule size and you will reach a daily target of 6 mg/kg.

• Adolescents >=17 Years

  • • Partial onset seizures, or Lennox–Gastaut syndrome

      • Instant-release

        • Initial: 25-50 mg daily taken orally for one week. Increase weekly by 25-50 mg/day. Take in 2 divided doses and adjust the dose according to your response.
        • Maintenance doses: 100-200 mg twice daily
        • Maximum daily intake: 1600 mg/day
        • Notification: Adult dose-response trials have not shown that higher doses than 400 mg/day increase effectiveness.

      • Extended-releaseQuedexyXR, TrokendiXR:

        • Initial: 25-50 mg once daily, once daily for one week. Increase weekly by 25-50 mg once daily. Titrate dosage to respond; longer intervals may be required between dose adjustments
        • Maintenance doses: 200-400 mg once daily
        • Maximum daily intake: 1600 mg/day

  • Primary generalized tonic-clonic seizures

    • • Release immediately:

      • Initial: 25-50 mg once daily in an oral dose for one week. Increase over 8 weeks in increments 25-50 mg/day in two divided doses. Titrate according to response
      • The normal maintenance dose is 200 mg twice daily. Use a slower initial titration rate at >2-week intervals.
      • Maximum daily intake: 1600 mg/day
      • Notice: Adult doses above 400 mg/day are not shown to be more effective in dose-response trials.

      • Extended-releaseQudexy, Trokendi and Trokendi XR

      • Initial dose: 25 mg to 50m once daily for one week. Increase weekly by 25 to 50mg/day increments once daily. Tirate according to response
      • Normal maintenance dose: 400mg once daily
      • Maximum daily intake: 1600 mg/day

Topiramate (Topamax), for seizures (Anticonvulsant monotherapy).

• Partial onset seizures, primary generalized-tonic-clonic seizures

  • Instant-release

  • Children from 2-10 years old:

    • Once daily, in the evening, 25 mg. If tolerated, the dose can be increased to 25 mg per day. The dose may be increased to 25 mg twice daily in the morning after the second week. The daily maintenance dose will then be decreased by 25 to 50 mg/day over a period of 5 to 7 weeks.
    • If additional seizure control is required and the therapy is acceptable, the dose may be increased by 25-50 mg/day at weekly intervals until the upper limit of the daily maintenance target dosing range.

    • Daily maintenance targets:

    • 11kgs or less:

      • 150-250 mg/day in two divided doses

    • 12-22 kg

      • 200-300 mg/day in 2 equal doses

    • 23 to 31 Kilograms

      • 200-350 mg/day in 2 equal doses

    • 32-38 kg

      • 250-350 mg/day in two divided doses

    • >38 kg

      • 250-400 mg/day in 2 equal doses

  • Children >=10 Years and Adolescents

    • 25 mg twice daily, once in the morning and again at night.
    • The dose may then be increased by 100 mg/day increments to achieve 200 mg twice a day. Weekly intervals are increased by 50 mg/day increments to 100 mg twice a day (week four dose).

  • Extended-releaseQudexy, Trokendi, XR:

    • Adolescents and children >=10 years

      • 50 mg daily, for a week.
      • You can increase the weekly dose by 50 mg/day increments to 200 mg once daily (week four-dose); after that, you may increase the weekly dose by 100 mg/day increments to 400 mg once daily.

Topamax Dose for Migraine Prophylaxis:

• Children aged 6-12 years, weight >=20 kg

  • Instant-release

    • 15 mg per mouth, once daily, for the first week. After a week, increase to 15 mg twice daily. Then, for seven days, increase to 25 mg twice daily.
  • The maximum daily intake is 200 mg/day

• Adolescents and children >=12 years

  • 25 mg/day taken orally once daily at night, for a period of 1 week. Then, increase in weekly increments of 25 mg/day as tolerated.

Topiramate pregnancy risk category: D

 

• Topiramate may cause harm to the foetus by crossing into other areas.
• Females should take topiramate to achieve effective contraception
• Metabolic acidosis can lead to fetal death and other adverse effects during pregnancy.
• Congenital malformations are more common in .

Breastfeeding

• Breastmilk contains topiramate.
• If the infant's dose of medication is less than 10%, breastfeeding is allowed. It should not exceed 25%.
• It can cause diarrhea and somnolence in infants who are breastfed.
• According the manufacturer of this product, it is important that you weigh the risks and benefits associated with breastfeeding therapy.

Topamax Dose Adjustment in Renal Disease:

• Creatinine clearance >=70mL/minute/1.73m 2

  • No dosage adjustments are included in the manufacturer's labeling

• Creatinine clearance 70mL/minute/1.73m 2

  • 50% dose reduction is required.

• Hemodialysis

  • 50 to 100mg twice daily. After dialysis, give a supplement of 50 to 100mg to the patient.

Topamax Dose Adjustment in Liver Disease:

• The manufacturer's labeling does not include any dosage adjustments.
• However, in severe hepatic impairment, topiramate clearance might be decreased.

Common Side Effects of Topamax (Topiramate):

• Central Nervous System:

  • Paresthesia
  • Fatigue
  • Drowsiness
  • Dizziness
  • Memory Impairment

• Endocrine & Metabolic:

  • Decreased Serum Bicarbonate
  • Hyperammonemia
  • Weight Loss

• Gastrointestinal:

  • Abdominal Pain
  • Anorexia
  • Dysgeusia
  • Nausea
  • Diarrhea

• Respiratory:

  • Upper Respiratory Tract Infection

• Miscellaneous:

  • Fever

Less Common Side Effects Of Topamax (Topiramate):

• Cardiovascular:

  • Flushing
  • Chest Pain

• Central Nervous System:

  • Disturbance In Attention
  • Lack Of Concentration
  • Depression
  • Insomnia
  • Mood Disorder
  • Hypoesthesia
  • Anxiety
  • Cognitive Dysfunction
  • Psychomotor Impairment
  • Headache
  • Nervousness
  • Ataxia
  • Behavioral Problems
  • Confusion
  • Hypertonia
  • Vertigo
  • Agitation
  • Exacerbation Of Depression
  • Speech Disturbance

• Dermatologic:

  • Alopecia
  • Pruritus
  • Skin Rash
  • Acne Vulgaris

• Endocrine & Metabolic:

  • Menstrual Disease
  • Intermenstrual Bleeding
  • Increased Gamma-Glutamyl Transferase
  • Increased Thirst

• Gastrointestinal:

  • Dyspepsia
  • Constipation
  • Gastroenteritis
  • Gastritis
  • Xerostomia
  • Gastroesophageal Reflux Disease
  • Ageusia

• Genitourinary:

  • Urinary Tract Infection
  • Premature Ejaculation
  • Decreased Libido
  • Urinary Frequency
  • Vaginal Hemorrhage
  • Cystitis
  • Urinary Incontinence
  • Dysuria

• Hematologic & Oncologic:

  • Hemorrhage
  • Anemia
  • Neoplasm

• Hypersensitivity:

  • Hypersensitivity Reaction

• Infection:

  • Viral Infection
  • Infection

• Neuromuscular & Skeletal:

  • Arthralgia
  • Asthenia
  • Muscle Spasm
  • Lower Extremity Pain

• Ophthalmic:

  • Conjunctivitis
  • Blurred Vision
  • Visual Disturbance

• Otic:

  • Otitis Media

• Renal:

  • Nephrolithiasis

• Respiratory:

  • Sinusitis
  • Cough
  • Rhinitis
  • Pharyngitis
  • Bronchitis
  • Epistaxis
  • Dyspnea

• Miscellaneous:

  • Accidental Injury
  • Language Problems

Uncommon side effects of Topamax:

• Cardiovascular:

  • Hypotension
  • Orthostatic Hypotension
  • Syncope

• Central Nervous System:

  • Suicidal Ideation
  • Suicidal Tendencies

• Endocrine & Metabolic:

  • Hyperchloremia
  • Increased Serum Total Protein
  • Increased Uric Acid

• Gastrointestinal:

  • Gingival Hemorrhage
  • Hematuria

• Hematologic & Oncologic:

  • Abnormal Serum Phosphorus Level
  • Decreased Neutrophils
  • Decreased White Blood Cell Count
  • Eosinophilia
  • Quantitative Disorders Of Platelets

• Hepatic:

  • Increased Serum Alkaline Phosphatase

• Neuromuscular & Skeletal:

  • Myalgia

• Ophthalmic:

  • Myopia
  • Scotoma
  • Visual Field Defect

• Renal:

  • Increased Blood Urea Nitrogen
  • Increased Serum Creatinine

Contraindications to Topamax, Topiramate

• Extended-release

  • Recent alcohol intake (i.e. within 6 hours prior and 6 hours following administration) (Trokendi extended release only)
  • Metabolic acidosis with concurrent Metformin (Qudexy extended Delivery only).

• Instant-release

  • There are no warnings stated on the packaging from the manufacturer.

• Canadian labeling

  • Hypersensitivity of topiramate to any component of the formula/container
  • Pregnancy

Warnings & Precautions

• CNS results

  • Use can cause cognitive dysfunction such as poor concentration, confusion and slowing down of the motor system.
  • It is crucial to exercise caution when operating machinery or driving.
  • It can also cause paraesthesia, dizziness, and ataxia.

• Encephalopathy / Hyperammonemia

  • Encephalopathy and hyperammonemia are possible causes of hyperammonemia. 
  • Inborn metabolic errors and reduced hepatic mitochondrial activity increase the risk of developing encephalopathy.

• Metabolic acidosis

  • This condition could be caused by decreased carbonic anhydrase activity and increased renal loss.
  • Risk factors include diabetes, kidney failure, ketogenic eating and status epilepticus.
  • Patients suffering from severe or persistent metabolic acidosis need to have their dosage reduced or stopped

• Hyperthermia/Oligohidrosis:

  • Exercise at high temperatures or strenuous activity is a dangerous way to increase your risk of hyperthermia and oligohidrosis.

• Ophthalmic effects

  • Children and adults should be treated for acute myopia.

• Calculus renal

  • Topiramate can have weak carbonic anhydrase inhibitory actions and increase your chance of developing kidney stones.
  • Ketogenic diets increase the risk while adequate water intake reduces it.

• Suicidal thoughts

  • Suicidal thoughts can result.

• Eating disorders

  • Topiramate has been associated with bulimia, anorexia and nervosa.
  • Compulsive exercising and over-exercising should be addressed.

Topiramate: Drug Interaction

Risk Factor C (Monitor therapy)
Alizapride	CNS depressants may have an enhanced CNS depressant impact.
Alpha-/Beta-Agonists (Indirect-Acting)	The serum concentration of Alpha-/Beta-Agonists may increase in response to carbonic anhydrase inhibitors (Indirect-Acting).
Amantadine	Amantadine's serum levels may rise in the presence of carbonic anhydrase inhibitors.
Amitriptyline	Amitriptyline's CNS depressive action may be strengthened by topiramate. The active metabolite(s) of amitriptyline's serum concentrations may rise in response to topiramate. Amitriptyline's serum levels may rise in response to topiramate.
Amphetamines	The excretion of amphetamines may be decreased by carbonic anhydrase inhibitors.
Anticholinergic Agents	Topiramate's harmful or toxic effects could be exacerbated.
Brexanolone	CNS Depressants may enhance the CNS depressant effect of Brexanolone.
Brimonidine (Topical)	May enhance the CNS depressant effect of CNS Depressants.
Bromopride	May enhance the CNS depressant effect of CNS Depressants.
Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Cannabis	May enhance the CNS depressant effect of CNS Depressants.
Chlorphenesin Carbamate	CNS depressants' harmful or toxic effects could be increased.
CNS Depressants	Other CNS depressants' harmful or toxic effects might be exacerbated.
Dimethindene (Topical)	CNS depressants may have an enhanced CNS depressant impact.
Doxylamine	CNS depressants may have an enhanced CNS depressant impact. Management: The producer of the pregnancy-safe drug Diclegis (doxylamine/pyridoxine) particularly advises against combining it with other CNS depressants.
Dronabinol	CNS depressants may have an enhanced CNS depressant impact.
Esketamine	CNS depressants may have an enhanced CNS depressant impact.
Flecainide	Flecainide's serum levels may rise in response to carbonic anhydrase inhibitors.
Fosphenytoin	Topiramate's serum concentration can drop. Fosphenytoin's serum levels may rise when topiramate is used.
HydrOXYzine	CNS depressants may have an enhanced CNS depressant impact.
Kava Kava	CNS depressants' harmful or toxic effects could be increased.
Lacosamide	Antiepileptic drugs (Sodium Channel Blockers) may make lacosamide more harmful or poisonous. Particularly, there may be an increased risk for bradycardia, ventricular tachyarrhythmias, or a longer PR interval.
Lithium	Topiramate may raise the level of lithium in the blood.
Lofexidine	CNS depressants may have an enhanced CNS depressant impact. Management: Separate drug interaction monographs go into further detail about the medications indicated as exceptions to this book.
Loop Diuretics	Topiramate's hypokalemic effects might be strengthened.
Magnesium Sulfate	CNS depressants may have an enhanced CNS depressant impact.
Memantine	Memantine's serum levels may rise in response to carbonic anhydrase inhibitors.
MetFORMIN	Topiramate may enhance the adverse/toxic effect of MetFORMIN.
MetyroSINE	CNS Depressants may enhance the sedative effect of MetyroSINE.
Mianserin	May diminish the therapeutic effect of Anticonvulsants.
Minocycline	May enhance the CNS depressant effect of CNS Depressants.
Mirtazapine	CNS Depressants may enhance the CNS depressant effect of Mirtazapine.
Nabilone	May enhance the CNS depressant effect of CNS Depressants.
Orlistat	May decrease the serum concentration of Anticonvulsants.
Phenytoin	Topiramate may raise the level of phenytoin in the blood. Topiramate's serum levels may drop if you take phenytoin.
Pioglitazone	Pioglitazone's serum levels may drop when topiramate is used.
Piribedil	Piribedil's CNS depressing effects may be enhanced by other CNS depressants.
Pramipexole	The sedative effects of pramipexole might be enhanced by CNS depressants.
Primidone	Primidone's harmful or poisonous effects may be exacerbated by carbonic anhydrase inhibitors. Particularly, rickets and osteomalacia. Primidone serum levels may be decreased by carbonic anhydrase inhibitors.
QuiNIDine	QuiNIDine excretion might be decreased by carbonic anhydrase inhibitors.
ROPINIRole	CNS Depressants may enhance the sedative effect of ROPINIRole.
Rotigotine	CNS Depressants may enhance the sedative effect of Rotigotine.
Rufinamide	May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced.
Selective Serotonin Reuptake Inhibitors	CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced.
Tetrahydrocannabinol	May enhance the CNS depressant effect of CNS Depressants.
Tetrahydrocannabinol and Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Trimeprazine	May enhance the CNS depressant effect of CNS Depressants.
Valproate Products	Topiramate may enhance the adverse/toxic effect of Valproate Products.
Risk Factor D (Consider therapy modification)
Blonanserin	CNS Depressants may enhance the CNS depressant effect of Blonanserin.
Buprenorphine	CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants.
CarBAMazepine	May decrease the serum concentration of Topiramate.
Chlormethiazole	May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used.
Droperidol	CNS depressants may have an enhanced CNS depressant impact. Consider lowering the dosage of droperidol or other CNS drugs (such as opioids or barbiturates) when they are used concurrently. In separate drug interaction monographs, exceptions to this monograph are covered in more detail.
Estrogen Derivatives (Contraceptive)	The serum levels of oestrogen derivatives may drop while taking topiramate (Contraceptive). Failure with contraception is possible. Management: Danger seems to be greatest at dosages of 200 mg or more of topiramate per day. The usefulness of utilising at least 50 mcg/day of ethinyl estradiol has been suggested, but this is debatable. Think about a nonhormonal method of birth control.
Flunitrazepam	CNS Depressants may enhance the CNS depressant effect of Flunitrazepam.
HYDROcodone	CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Mefloquine	May reduce an anticonvulsant's therapeutic impact. Anticonvulsant serum concentrations may be reduced by mefloquine. Treatment: Mefloquine should not be used to prevent malaria in those who have a history of convulsions. Keep track of anticonvulsant levels and treatment results.
Methenamine	The therapeutic effects of methenamine may be diminished by carbonic anhydrase inhibitors. Management: Take into account avoiding this pairing. If you use a carbonic anhydrase inhibitor at the same time as methenamine, keep an eye out for any diminished therapeutic effects.
Methotrimeprazine	The CNS depressing action of methotrimeprazine may be enhanced by CNS depressants. The CNS depressant action of CNS Depressants may be strengthened by methotrimeprazine. Management: Start concurrent methotrimeprazine therapy while reducing the adult dose of CNS depressants by 50%. Only once a clinically effective dose of methotrimeprazine has been established should additional CNS depressant dosage modifications be made.
Opioid Agonists	CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
OxyCODONE	CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Perampanel	May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination.
Progestins (Contraceptive)	Progestin levels in the serum may drop while taking topiramate (Contraceptive). Treatment: Inform patients that this combination may result in decreased contraceptive efficacy. Think about including an additional (non-hormonal) type of birth control.
Salicylates	Could intensify the hazardous or harmful effects of carbonic anhydrase inhibitors. This identical combination may increase salicylate toxicity. Management: Whenever you can, stay away from these pairings. Use of dichlorphenamide with aspirin at high doses is not advised. If a different combination is used, patients should be closely watched for side effects. There have been reports of tachypnea, anorexia, lethargy, and coma.
Sodium Oxybate	CNS depressants may have an enhanced CNS depressant impact. Management: Take into account substitutes for combined use. Reduce the doses of one or more medications when simultaneous use is necessary. It is not advised to use sodium oxybate with alcoholic beverages or hypnotic sedatives.
Suvorexant	Suvorexant's CNS depressing effects may be amplified by other CNS depressants. Treatment: Suvorexant and/or any other CNS depressant dosage reduction may be required.
Tapentadol	CNS depressants may have an enhanced CNS depressant impact. Treatment: When feasible, refrain from using tapentadol and benzodiazepines or other CNS depressants simultaneously. Only in the event that other treatment choices are insufficient should these medications be combined. Limit the duration and dosage of each medicine when used together.
Thiazide and Thiazide-Like Diuretics	Topiramate's hypokalemic effects might be strengthened. The blood concentration of topiramate may rise in response to thiazide and thiazide-like diuretics. When using a thiazide diuretic, monitor for elevated topiramate levels and any negative consequences (such as hypokalemia). Serum potassium levels should be closely watched when receiving concurrent treatment. There may be a need to lower topiramate dosage.
Zolpidem	CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol.
Risk Factor X (Avoid combination)
Alcohol (Ethyl)	May intensify topiramate's CNS depressive effects. The blood content of topiramate may rise by drinking alcohol (Ethyl). Use with the extended-release topiramate capsules only, please (Trokendi XR). Moreover, in the later part of the dose interval, topiramate concentrations may be below therapeutic levels. Treatment: It is not advised to consume alcohol concurrently within six hours after taking Trokendi XR, an extended-release topiramate. Topiramate should never be combined with alcohol, and if it must be, only with the utmost caution.
Azelastine (Nasal)	CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal).
Bromperidol	May enhance the CNS depressant effect of CNS Depressants.
Carbonic Anhydrase Inhibitors	The negative or hazardous effects of other carbonic anhydrase inhibitors might be heightened. There have been reports of acid-base abnormalities developing when oral and ophthalmic carbonic anhydrase inhibitors are used simultaneously. Management: If at all feasible, refrain from using multiple carbonic anhydrase inhibitors simultaneously.
Orphenadrine	The CNS depressing action of orphenadrine may be enhanced by CNS depressants.
Oxomemazine	May enhance the CNS depressant effect of CNS Depressants.
Paraldehyde	CNS Depressants may enhance the CNS depressant effect of Paraldehyde.
Thalidomide	CNS Depressants may enhance the CNS depressant effect of Thalidomide.
Ulipristal	Topiramate may decrease the serum concentration of Ulipristal.

Monitoring parameters:

• Electrolytes in serum
• Ammonia levels
• Hydration status
• Seizure frequency
• Renal function tests
• Glaucoma symptoms/intraocular pressure
• Suicidal thoughts/behavioral and behavioral changes
• Weight and eating habits

How do you administer Topamax (Topiramate).

• It is best to take the medication orally without crushing or chewing.
• You can also open QudexyXR or Sprinkle capsules to sprinkle their entire contents onto a small amount of soft food. 
• These capsules can be opened immediately and eaten whole, without needing to be chewed.
• Do not keep it. Stop drinking alcohol with Trokendi XR tablets within 6 hours after administration and 6 hours thereafter.

Mechanism of Topamax (Topiramate),:

• It increases gamma aminobutyric (GABA) activity and blocks neuronal voltage dependent sodium channels. 
• It inhibits carbonic anhydrase and antagonizes AMPA/kainate glucose.

Notice:

• The capsule and the tablet are bioequivalents to immediate-release formulations. Extended-release capsules (Trokendi XR) are twice daily administered and are bioequivalent to immediate-release formulations.

Absorption:

• Fast and efficient. The immediate-release formulation is unaffected by food. A single TrokendiXR dose taken with high-fat meals reduced the T by around 8 hours and increased Cmax by 37% Repeated administrations of TrokendiXR reduce this effect significantly. After a single QudexyXR dosage, the Tmax was delayed 4 hours.

Protein binding:

• 15% to 41% (inversely proportional plasma concentrations).

Metabolism:

• The hepatic metabolism is restricted to hydrolysis, hydrogenation and glucuronidation. 
• Patients receiving enzyme inducers (e.g.Carmazepine,Phenytoin. There is evidence of renal tubular absorption.

Bioavailability:

• 80% (immediate-release)

Eliminating half-life:

Release immediately:

If you are receiving any concomitant enzyme inducers or valproic acids.

• Hypothermia in neonates (full-term).: 43 hours
• Infants and children 9 months to 4 years10.4 hours (range: 8.5-8.3 hours).
• Children aged 4-7 yearsAverage range: 7.7 to 8.8 hours
• Children aged 8-11 yearsAverage range: 11.3 to 11 hours
• Children and adolescents 12-17 years oldAverage range: 12.3 to 12.8 Hours

Concomitant use of enzyme inducers (eg carbamazepine or phenytoin):

• Hypothermia in neonates (full-term).: 26.5 Hours
• Infants and children 9 months to 4 years6.5 hours (range 3.75-10.2 hours).
• Children and adolescents 4-17 years old7.5 hours

Receiving Valproic acid:

• Infants and children 9 months to 4 Years:9.2 hours (range 7.23 to 12.4 hours).
• Adults: 19-23 hours (mean: 21hrs)
• Adults with severe renal impairment: 59 +- 11 Hours

Extended-release

• QudexyXR:56 hours
• Trokendi:31 hours

Time until peak serum concentrations are reached:

Release immediately:

• Hypothermia in neonates (full-term), 3.8 hours
• Infants and children 9 months to 4 years: 3.7 Hours (range: 1.5-10.2 Hours).
• Children aged 4-17 years: Average range: 1 to 2 hours
• Adults: 2 Hours; range: 1.4-4.3 hours

Extended-release

• QudexyXR: 20 Hours
• TrokendiXR: 24 Hours

Excretion: Occurs in the urine (70% for unchanged drug); could undergo renal tubular absorption.

Topiramate Brand Names (International):

• Qudexy XR
• Topamax
• Topamax Sprinkle
• Trokendi XR
• Abbott-Topiramate
• ACCEL-Topiramate
• AG-Topiramate
• APO-Topiramate
• AuroTopiramate
• DOM-Topiramate
• GLN-Topiramate
• JAMP-Topiramate
• Mar-Topiramate
• MINTTopiramate
• MYLAN-Topiramate
• PHL-Topiramate
• PMS-Topiramate
• PRO-Topiramate
• RANTopiramate
• SANDOZ Topiramate
• TEVA-Topiramate
• Topamax
• Topamax Sprinkle
• Acomicil
• Conviban
• Epilramate
• Epimate
• Epiramat
• Epitomax
• Epitop
• Etopira
• Fagodol
• Gabatopa
• Ipramax
• Moramax
• Piramed
• Pradox
• Seziril
• Tamate
• Tiramate
• Topagan
• Topamac
• Topamax
• Topamax Sprinkle
• Topictal
• Topilepsin
• Topimax
• Topina
• Topinmate
• Topirol
• Topiromax
• Topiron
• Topirva
• Topitrim
• Topmate
• Topnotch
• Topomac
• Topvex
• Toramat
• Toramate

Topiramate Brand Names in Pakistan:

Topiramate 25 mg Tablets
Amtec	Shrooq Pharmaceuticals
Apimate	Tg Pharma
Brainamax	Friends Pharma (Pvt) Ltd
Epik	Pharmevo (Pvt) Ltd.
Epimate	Pharmevo (Pvt) Ltd.
Hitop	Hilton Pharma (Pvt) Limited
Legent	Amarant Pharmaceuticals (Pvt)
Seziril	Medizan Labs (Pvt) Ltd
Siezab	Macter International (Pvt) Ltd.
Tics	Genix Pharma (Pvt) Ltd
Tolymax	Medisure Laboratories Pakistan (Pvt.) Ltd.
Tomax	Schazoo Zaka
Tomigraine	Obs
Topagen	Genetics Pharmaceuticals
Topamax	Janssen-Cilag
Topamid	Avital Pharma
Toperatec 3h	Hamaz Pharmaceutical (Pvt) Ltd.
Topilep	Cellgene Pharmaceuticals International
Topirama	Platinum Pharmaceuticals (Pvt.) Ltd.
Topirat	Gray`S Pharmaceuticals
Topiro	Adamjee Pharmaceuticals (Pvt) Ltd.
Topmate	Efroze Chemical Industries (Pvt) Ltd.
Toprex	Hansel Pharmacueutical Pvt (Ltd)
Topte	S.J. & G. Fazul Ellahie (Pvt) Ltd.
Torate	Consolidated Chemical Laboratories (Pvt) Ltd.
Tritop	Semos Pharmaceuticals (Pvt) Ltd.
Zopir	Glitz Pharma
Zopiramate	Mass Pharma (Private) Limited

 

Topiramate 50 mg Tablets
Amtec	Shrooq Pharmaceuticals
Apimate	Tg Pharma
Awapram	Usawa Pharmaceuticals
Awapram	Usawa Pharmaceuticals
C-Zar	Mass Pharma (Private) Limited
Epimax	Envoy Pharma
Hitop	Hilton Pharma (Pvt) Limited
Legent	Amarant Pharmaceuticals (Pvt)
Seziril	Medizan Labs (Pvt) Ltd
Siezab	Macter International (Pvt) Ltd.
Tics	Genix Pharma (Pvt) Ltd
Tolymax	Medisure Laboratories Pakistan (Pvt.) Ltd.
Tomax	Schazoo Zaka
Tomigraine	Obs
Topadix	Neo Medix
Topagen	Genetics Pharmaceuticals
Topamax	Janssen-Cilag
Topamid	Avital Pharma
Topawan	Swan Pharmaceuticals(Pvt) Ltd
Topcal	Caraway Pharmaceuticals
Toperatec 3h	Hamaz Pharmaceutical (Pvt) Ltd.
Topilep	Cellgene Pharmaceuticals International
Topirama	Platinum Pharmaceuticals (Pvt.) Ltd.
Topirat	Gray`S Pharmaceuticals
Topiro	Adamjee Pharmaceuticals (Pvt) Ltd.
Topmate	Efroze Chemical Industries (Pvt) Ltd.
Toprex	Hansel Pharmacueutical Pvt (Ltd)
Topte	S.J. & G. Fazul Ellahie (Pvt) Ltd.
Torate	Consolidated Chemical Laboratories (Pvt) Ltd.
Tritop	Semos Pharmaceuticals (Pvt) Ltd.
Zopir	Glitz Pharma

 

Topiramate 100 mg Tablets
Amtec	Shrooq Pharmaceuticals
Engrax	English Pharmaceuticals Industries
Hitop	Hilton Pharma (Pvt) Limited
Legent	Amarant Pharmaceuticals (Pvt)
Mustop	Navegal Laboratories
Tics	Genix Pharma (Pvt) Ltd
Tics	Genix Pharma (Pvt) Ltd
Tomax	Schazoo Zaka
Tomigraine	Obs
Tomigraine	Obs
Topadix	Neo Medix
Topagen	Reko Pharmacal (Pvt) Ltd.
Topcal	Caraway Pharmaceuticals
Topcal	Caraway Pharmaceuticals
Topirama	Platinum Pharmaceuticals (Pvt.) Ltd.
Topirax	Ferroza International Pharmaceuticals (Pvt) Ltd.
Topirax	Ferroza International Pharmaceuticals (Pvt) Ltd.
Topiro	Adamjee Pharmaceuticals (Pvt) Ltd.
Topiro	Adamjee Pharmaceuticals (Pvt) Ltd.

 

Topiramate 200 mg Tablets
Engrax	English Pharmaceuticals Industries
Tamat	Global Pharmaceuticals
Tics	Genix Pharma (Pvt) Ltd
Tomigraine	Obs
Topirax	Ferroza International Pharmaceuticals (Pvt) Ltd.