Topiramate Treatment for Alcoholism

Topiramate is an anticonvulsant medication used to treat seizures stemming from the presence of epilepsy or a separate seizure disorder called Lennox-Gaustaut syndrome; in addition, doctors frequently prescribe the medication in order to prevent the return of symptoms in people with a history of migraine headaches. According to a variety of scientific studies conducted in the 2000s, topiramate can also help doctors treat people with alcoholism by decreasing alcohol cravings and promoting a decrease in alcohol intake. Unlike other medications used to treat alcoholism, topiramate can be successfully prescribed to people still actively consuming large amounts of alcohol.

Topiramate Basics

Topiramate is sold in the United States under the brand names Topamax and Topiragen. Available forms of the medication include tablets, as well as capsules that can be swallowed whole or broken open and sprinkled on top of food. When used in the treatment of seizures, common adult dosages of topiramate range anywhere from 25 mg to 400 mg per day. When used to prevent the onset of migraines, common adult dosages of the drug range anywhere from 25 mg to 100 mg per day. While topiramate can control seizures, it will not cure them. Similarly, while use of the drug can prevent migraine symptoms, it will not cure the underlying conditions that cause migraines, or reduce the symptoms of a migraine once they appear.

Topiramate belongs to a class of substances called GABA receptor agonists. All substances in this class encourage the production of GABA (gamma-aminobutyric acid), a widespread neurotransmitting chemical in the brain and spinal cord that helps prevent overexcitement of vital nerve cells by slowing down their rate of communication with their neighboring cells. In addition to encouraging GABA production, topiramate simultaneously slows down production of another widespread neurotransmitter called glutamate, which promotes increasing levels of nerve cell communication.

Effects on the Alcoholic Brain

Generally speaking, alcoholism is the result of heavy, frequent drinking that significantly alters normal function in certain parts of the brain. Among these alterations are an increase in the normal production of nerve-exciting glutamate and a decrease in the normal production of nerve-calming GABA. If an active alcoholic stops drinking abruptly, the long-term changes in glutamate and GABA levels will support an abnormally high level of nerve excitability within the brain. Consequences of this extreme excitability include classic symptoms of alcohol withdrawal such as mental agitation, irritability, anxiety, and the onset of involuntary muscle tremors. In its extreme form, alcohol withdrawal can also produce full-blown seizures and a dangerous medical complication called delirium tremens (the DTs).

By helping to restore normal levels of GABA and glutamate, topiramate helps reduce the potential for excessive brain excitability. In active alcoholics, this reduction in excitability levels decreases glutamate-related cravings for continued alcohol intake, and also decreases the number of days on which extreme alcohol intake occurs, according to a study published in 2003 by researchers at the University of Texas Health Science Center at San Antonio. In recovering alcoholics who have decided to stop drinking, use of the medication can diminish withdrawal symptoms and increase periods of abstinence in the critical, early stages of treatment. A second study published in 2011 in BMC Psychiatry revealed additional potential benefits of low-dose topiramate treatment in recovering alcoholics, including a reduction in related symptoms of depression and medically serious anxiety.

The crucial difference between topiramate and the medications officially approved for alcoholism treatment-including naltrexone (ReVia), acamprosate (Campral) and disulfiram (Antabuse)-is the timing of usage. While both active and abstinent alcoholics can use topiramate, only abstinent alcoholics can use naltrexone, acamprosate, or disulfiram. In real-world terms, this means that topiramate can potentially reach a wide cross-section of drinkers and help encourage abstinence, while other medications for alcoholism can only reinforce abstinence in people who have already gotten over the major hurdle of stopping their alcohol intake.

Considerations

Use of topiramate can lead to a wide variety of side effects in active and recovering alcoholics, including numbness or tingling in the hands or feet, loss of mental clarity, loss of normal memory function, diarrhea, unexplained weight loss, decreased sweat production, fatigue, drowsiness, dizziness, excessive acid levels in the blood, kidney stones, and the onset of suicidal thinking or active suicide attempts. While some doctors in the United States currently prescribe topiramate for the treatment of alcoholism, the medication is not approved for this purpose by the US Food and Drug Administration. This type of prescribing activity, known as “off-label” prescribing, is not illegal. However, researchers typically don’t have much evidence on the long-term effects of medications prescribed in this manner. As of 2013, this lack of long-term perspective applies to the use of topiramate for alcoholism treatment.