Topiramate (brand name Topamax) is an anticonvulsant (antiepilepsy) drug. In late 2012, topiramate was approved by the United States Food and Drug Administration (FDA) in combination with phentermine for weight loss. The drug had previously been used off-label for this purpose. Topiramate was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil Pharmaceutical. Topiramate was first approved in the US in 1996. Generic versions are available in Canada and these were approved by the FDA in September 2006. Mylan Pharmaceuticals was recently granted final approval for generic topiramate 25, 100, and 200 mg tablets and sprinkle capsules by the FDA for sale in the United States. 50 mg tablets were granted tentative approval. The last patent for topiramate in the U.S. was for pediatric use; this patent expired on February 28, 2009.
Topiramate is used to treat epilepsy in children and adults, and it was originally used as an anticonvulsant. In children, it is indicated for the treatment of Lennox-Gastaut syndrome, a disorder that causes seizures and developmental delay. It is also Food and Drug Administration (FDA) approved for, and most frequently prescribed for, the prevention of migraines. Psychiatrists have used topiramate to treat bipolar disorder, although the available evidence does not support its use in any phase of bipolar disorder treatment. A more recent review, published in 2010, suggested a benefit of topiramate in the treatment of symptoms of borderline personality disorder, however the authors note that this was based only on one randomized controlled trial and requires replication. Also the Authors noted that the long-term effects have not been studied.
This drug has been used successfully as a treatment for alcoholism,methamphetamine addiction, cocaine addiction, obesity and antipsychotic-induced weight gain. This drug is also widely used to treat migraines due to the effect it has on the blood vessels in the brain. It is used as a preventative for atypical migraine sufferers. It widens the blood vessels in the brain which become restricted by increased serotonin levels. It has been found to be increasingly effective for migraine sufferers with limited side effects.
The U.S. Food and Drug Administration (FDA) has notified prescribers that topiramate can cause acute myopia and secondary angle closure glaucoma in a small subset of people who take topiramate regularly. The symptoms, which typically begin in the first month of use, include blurred vision and eye pain. Discontinuation of topiramate may halt the progression of the ocular damage, and may reverse the visual impairment.
Preliminary data suggests that, as with several other anti-epileptic drugs, topiramate carries an increased risk of congenital malformations. This might be particularly important for women who take topiramate to prevent migraine attacks. In March 2011 the FDA notified healthcare professionals and patients of an increased risk of development of cleft lip and/or cleft palate (oral clefts) in infants born to women treated with Topamax (topiramate) during pregnancy and placed it in Pregnancy Category D.
Topiramate has been associated with a statistically significant increase in suicidality, and "suicidal thoughts or actions" is now listed as one of the possible side effects of the drug "in a very small number of people, about 1 in 500." 
Topiramate has many drug-drug interactions. Some of the most common are listed below:
A specific antidote is not available. Treatment is entirely supportive.
Detection in body fluids
Blood, serum or plasma topiramate concentrations may be measured using immunoassay or chromatographic methods to monitor therapy, confirm a diagnosis of poisoning in hospitalized patients or to assist in a medicolegal death investigation. Plasma levels are usually less than 10 mg/L during therapeutic administration, but can range from 10–150 mg/L in overdose victims.
People taking topiramate should be aware of the following risks:
Avoid activities requiring mental alertness and coordination until drug effects are realized.
Topiramate may impair heat regulation, especially in children. Use caution with activities leading to an increased core temperature, such as strenuous exercise, exposure to extreme heat, or dehydration.
Topiramate is quickly absorbed after oral use. Most of the drug (70%) is excreted in the urine unchanged. The remainder is extensively metabolized by hydroxylation, hydrolysis, and glucuronidation. Six metabolites have been identified in humans, none of which constitutes more than 5% of an administered dose.
Several cellular targets have been proposed to be relevant to the therapeutic activity of topiramate. These include (1) voltage-gated sodium channels; (2) high-voltage-activated calcium channels; (3) GABA-A receptors; (4) AMPA/kainate receptors; and (5) carbonic anhydrase isoenzymes. There is evidence that topiramate may alter the activity of its targets by modifying their phosphorylation state instead of by a direct action. The effect on sodium channels could be of particular relevance for seizure protection. Although topiramate does inhibit high-voltage-activated calcium channels, the relevance to clinical activity is uncertain. Effects on specific GABA-A receptor isoforms could also contribute to the antiseizure activity of the drug. Topiramate selectively inhibits cytosolic (type II) and membrane associated (type IV) forms of carbonic anhydrase. The action on carbonic anhydrase isoenzymes may contribute to the drug’s side-effects, including its propensity to cause metabolic acidosis and calcium phosphate kidney stones.
Topiramate inhibits maximal electroshock and pentylenetetrazol-induced seizures as well as partial and secondarily generalized tonic-clonic seizures in the kindling model, findings predictive of a broad spectrum of activities clinically. Its action on mitochondrial permeability transition pores has been proposed as a mechanism.
While many anticonvulsants have been associated with apoptosis in young animals, animal experiments have found that topiramate is the only anticonvulsant that does not induce apoptosis in young animals at doses needed to produce an anticonvulsant effect.
^Maryanoff, BE; Nortey, SO; Gardocki, JF; Shank, RP; Dodgson, SP (1987). "Anticonvulsant O-alkyl sulfamates. 2,3:4,5-Bis-O-(1-methylethylidene)-beta-D-fructopyranose sulfamate and related compounds". Journal of Medical Chemistry30 (5): 880–7. doi:10.1021/jm00388a023. PMID3572976.
^Maryanoff, BE; Costanzo, MJ; Nortey, SO; Greco, MN; Shank, RP; Schupsky, JJ; Ortegon, MP; Vaught, JL (1998). "Structure-activity studies on anticonvulsant sugar sulfamates related to topiramate. Enhanced potency with cyclic sulfate derivatives". Journal of Medical Chemistry41 (8): 1315–43. doi:10.1021/jm970790w. PMID9548821.
^B. E. Maryanoff and J. F. Gardocki, "Anticonvulsant sulfamate derivatives", U.S. Patent number 4,513,006 (1985)
^Verrotti, A; Scaparrotta, A; Agostinelli, S; Di Pillo, S; Chiarelli, F; Grosso, S (August 2011). "Topiramate-induced weight loss: a review.". Epilepsy Research95 (3): 189–99. doi:10.1016/j.eplepsyres.2011.05.014. PMID21684121.Cite uses deprecated parameters (help)
^Kramer, CK; Leitão, CB; Pinto, LC; Canani, LH; Azevedo, MJ; Gross, JL (May 2011). "Efficacy and safety of topiramate on weight loss: a meta-analysis of randomized controlled trials.". Obesity Reviews12 (5): e338–47. doi:10.1111/j.1467-789X.2010.00846.x. PMID21438989.
^Hahn, MK; Cohn, T; Teo, C; Remington, G (January 2013). "Topiramate in schizophrenia: a review of effects on psychopathology and metabolic parameters.". Clinical schizophrenia & related psychoses6 (4): 186–96. doi:10.3371/CSRP.HACO.01062013. PMID23302448.
^Mahmood, S; Booker, I; Huang, J; Coleman, CI (February 2013). "Effect of topiramate on weight gain in patients receiving atypical antipsychotic agents.". Journal of Clinical Psychopharmacology33 (1): 90–4. doi:10.1097/JCP.0b013e31827cb2b7. PMID23277264.
^Ferrari, A; Tiraferri, I; Neri, L; Sternieri, E (September 2011). "Clinical pharmacology of topiramate in migraine prevention.". Expert Opinion on Drug Metabolism & Toxicology7 (9): 1169–81. doi:10.1517/17425255.2011.602067. PMID21756204.
^Andrus, MR; Gilbert, E (November 2010). "Treatment of civilian and combat-related posttraumatic stress disorder with topiramate.". The Annals of Pharmacotherapy44 (11): 1810–6. doi:10.1345/aph.1P163. PMID20923947.
^Hoopes, SP; Reimherr, FW; Hedges, DW; Rosenthal, NR; Kamin, M; Karim, R; Capece, JA; Karvois, D (2003). "Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures". The Journal of clinical psychiatry64 (11): 1335–41. doi:10.4088/JCP.v64n1109. PMID14658948.
^Goswami D, Kumar A, Khuroo AH, et al. Bioanalytical LC-MS/MS method validation for plasma determination of topiramate in healthy Indian volunteers. Biomed. Chromatogr. 23: 1227-1241, 2009.
^Brandt C; Elsner H; Füratsch N et al. (2010). "Topiramate overdose: a case report of a patient with extremely high topiramate serum concentrations and nonconvulsive status epilepticus". Epilepsia51 (6): 1090–1093. doi:10.1111/j.1528-1167.2009.02395.x. PMID19889015.
^R. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 8th edition, Biomedical Publications, Foster City, CA, 2008, pp. 1567-1569.