Topiramate is another common off-label treatment for alcohol use disorder. It has shown strong all-around effectiveness in clinical trials and is available generically.
Topiramate is best for:
- Limiting alcohol cravings
- Improving anxiety-related drinking
- Reducing overall consumption
- Treating physical addiction symptoms
Is it right for you? Skip to pros and cons
How Does Topiramate Work?
Topiramate is generally prescribed to treat seizures and migraines, but also seems to help with alcohol use disorder. People who take it appear to have fewer cravings. They also report less pleasure from alcohol, and have fewer anxiety-related drinking urges. Topiramate even seems to work better than naltrexone in some studies.
Topiramate and Brain Chemistry
The science behind topiramate seems to be similar to that of acamprosate and baclofen. All three of these medications work on something called GABA receptors—a part of your brain that controls how active your nervous system is. When you drink frequently and excessively, these receptors are triggered, and they eventually become less sensitive. Here are the differences between the medications:
- Baclofen likely works by replacing the role of alcohol in your brain, making your GABA receptors feel as if they are still getting alcohol and reducing your cravings.
- Acamprosate appears to rebalance your GABA receptors with their opposite receptors, helping your nervous system get back to normal after you stop drinking.
- Topiramate appears to do a little of both, restimulating your GABA receptors and blocking some glutamate activity (GABA’s opposite).
Unlike acamprosate, topiramate seems to have this effect while you are still drinking. It also appears to block some of the dopamine response to alcohol, making it somewhat similar to naltrexone. In other words, topiramate is a good all-around medication, covering many of the bases that the others cover one by one. This versatility, combined with its overall success rate in studies, has motivated many doctors to start prescribing topiramate for alcohol use disorder.
Why Isn’t Topiramate More Well Known?
Part of the issue is that topiramate is considered “off-label.” An off-label medication is a drug approved for one purpose, but prescribed for another because a doctor deems it safe and useful. While there are plenty of studies to support topiramate for alcohol addiction, the FDA has only approved it for seizures and migraines. As a result, topiramate keeps a lower profile. However, this medication is still legal to prescribe for alcohol dependence, and with good clinical results even at a low dose, topiramate can be an excellent option to consider.
Upsides and Downsides
As a medication, topiramate has the benefit of being non-addictive, and doesn’t show any signs of generating physical dependency. Like baclofen, topiramate may also help with other addictions such as cocaine. The medication has also demonstrated some positive effects on depression and anxiety, which are common drinking triggers for people in recovery.
On the other hand, topiramate shows few signs of helping with alcohol withdrawal. It also needs to be introduced gradually over a period of several weeks to avoid side effects. Finally, topiramate appears to be better at reducing drinking than maintaining abstinence, so it may be a better choice for harm reduction than quitting alcohol. That said, if abstinence doesn’t seem likely for a person, reducing their consumption with topiramate may still have a big health impact.
Topiramate’s main side effects include:
- Numbness or tingling
- Memory Impairment
- Weight loss
- Concentration issues
- Missed period or excessive bleeding
While generally manageable, these side effects can be more severe than with other medications, and up to 20 percent of people stop using topiramate because of them.
Like with acamprosate and gabapentin, people on topiramate should be monitored for suicidal behavior, which is rare, but serious. Kidney stones and increased ammonia production have been reported, so people with kidney issues should exercise caution. Finally, topiramate may interfere with some oral contraceptives, and has shown the ability to cause birth deformities in some infants. Women of childbearing age should discuss their plans with their doctor before taking topiramate.
Is Topiramate For You?
Topiramate May Help If:
- You want to reduce how much you drink
- You struggle with cravings and physical addiction symptoms
Topiramate May Not Be Best If:
- You are pregnant
- You have kidney disease
- You have a history of depression or suicidal thoughts
Although topiramate may not be approved by the FDA to reduce drinking, it appears to be very effective and safe for this purpose. Because it helps reduce both alcohol cravings and the pleasure effects of drinking, it can be a good stand-in for naltrexone. Because it helps rebalance your brain chemistry, topiramate can also be a good substitute for acamprosate or gabapentin. In fact, overall, this medication can do a little bit of everything. Side effects can be more troublesome than with some other options, but they are usually manageable. As a result, although not on the FDA’s official list, topiramate is one of the better choices for fighting alcohol addiction. If you’ve had trouble with any of the other approved medications, this option may work for you.
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