Semaglutide and tirzepatide have ushered in a new era of medications for weight loss and long-term weight maintenance. But there is an older medicine on the list of those prescribed for obesity that can be used in a number of ways directly and indirectly for weight loss.
Topiramate was first approved in the mid-1990s as a treatment for seizures and epilepsy for both adults and kids above age two. It then added an indication for migraine prevention in adults in 2004. Since that time, it has been studied in many settings, adding off-label applications for conditions ranging from the prevention of cluster headaches to the treatment of neuropathic pain, essential tremors, and idiopathic intracranial hypertension. It also offers an adjunctive option in many mental health conditions: borderline personality disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and Tourette syndrome to name a few.
Before we go any further, it’s important to know that topiramate is not without potential side effects. In medical school, it was sometimes called “Dopamax” (after the medicine’s brand name, Topamax) to acknowledge the medicine’s penchant for making some people feel groggy or ‘dopey’. Importantly, this side effect, if it happens, will go away soon after the medication is stopped. Topiramate is also known to interact disruptively with several forms of birth control, and if taken during pregnancy, can increase the risk of birth defects. Topiramate may also raise the risk of certain types of kidney stones and cause others to feel tingling in their fingers or toes. Recognizing this potential for side effects, treatment should always start at a low dose, increasing slowly over time only if the benefit of a lower dose wears off and if side effects aren’t present or are easily managed.
It’s important to acknowledge, too, that officially, topiramate is only indirectly approved for weight loss itself. It was approved in 2012 for the standard BMI criteria (> 30 kg/m2 alone or > 27 kg/m2 with history of a weight-related condition) as a part of the combination pill phentermine-topiramate XR, which has shown solid results with an average of 10-12% total body weight loss over 1-2 years with maintenance thereafter. Phentermine alone is also FDA-approved for weight loss, so it stands to reason that topiramate received the FDA’s implicit blessing when it approved the combination pill, noting that the combination offers greater benefit than phentermine alone. Ironically, despite all of the data available on topiramate, we don’t actually know exactly how it works as a potential treatment for all of these conditions.
Having said all this, we use topiramate regularly as either a primary medication for weight loss or as an adjunctive, secondary treatment. The list of potential weight-related uses isn’t quite as long as the uses listed above, but it’s still impressive for a generic medication:
• Binge eating disorder
• Night eating
• Reduced interest in carbonated beverages, such as soda
• Alcohol use disorder
• Antipsychotic-associated weight gain
• Use alongside metformin for treatment of polycystic ovary syndrome (PCOS)
Multiple studies show benefit in the treatment of binge eating disorder. One single-center, randomized controlled trial from 2007 showed that binge eating was remitted within 5 weeks in more than 50% of participants. Clinically we see improvements even in patients who may not meet the full criteria for binge eating disorder, but who have binge eating episodes on a more intermittent (but still clinically relevant) basis.
We also see metabolic benefit in populations who are prescribed antipsychotics: second-generation versions like quetiapine and olanzapine served as a great breakthrough for control of a number of psychiatric conditions and are also used off-label for sleep, for example. As a category, though, they have the potential to cause substantial increases in appetite that lead to weight gain and other metabolic sequelae, including increased cholesterol and increased blood sugar. Topiramate can help curb this.
Among the older class of weight loss medicines, topiramate is one of the few that can be taken at night (if anything, it makes it easier for some to fall asleep), which has lent itself to use for episodes of late night and/or overnight eating. Many patients report that the medicine makes carbonated drinks taste ‘flat’ – like a can a soda was left open for 2-3 days – which reduces interest in these often-higher-calorie drinks. There is also robust evidence to show topiramate’s benefit for alcohol use disorder (AUD); it is used in some settings as first-line therapy for AUD. Alcohol can be a major source of calories for some patients; if we can reduce intake of alcohol, weight loss often comes more easily.
As more data from both clinical and research settings comes in for the newer class of medications like semaglutide and tirzepatide, we are learning that these medications may be beneficial in many of the off-label conditions for which we use topiramate. For now, topiramate will continue to serve as a primary treatment for some and as a very helpful secondary or adjunctive agent for others. As a generic medication, too, the price is right: cost can be as little as $10 per month.
Is topiramate a good option for you? Book an initial visit with Dr. Millard. We take the time to dive deep into your medical history and current nutrition patterns to figure out whether topiramate could be part of the best plan for you!
