US Brand Name: Topamax
A link here will take you to the official website for the drug.

Other Brand Names: Epitomax (Finland, France)
Topamac (Argentina, Germany, Greece)
Топамакс / Topamax (Russia)

Other Forms: Sprinkle Capsules

Days to Reach a Steady State: Four days.
When you're fully saturated with the medication and less prone to peaks and valleys of effects. You still might have peaks of effect after taking many meds, but with a lot of the meds you'll have fewer valleys after this point. In theory anyway.

Like any anticonvulsant, if you've been taking Topamax (topiramate) for more than a couple months and you're up to or above 200mg a day you just can't stop Topamax cold turkey if you're not at the therapeutic dosage for another anticonvulsant that you know works for you, otherwise you risk partial-complex, absence seizures or even tonic-clonic grand mals, despite your never having had a seizure disorder before!  The risk is worse if you're taking a lithium variant, and/or any antidepressant, especially Wellbutrin (bupropion).  Anyone with a history of a seizure disorder who needs to stop taking an anticonvulsant cold turkey needs to be discussing that with two neurologists and not getting your information from some stupid web site.  Get off your computer and start making appointments!
If you've worked your way up to a particular dosage, it's usually best to spend this many days at the next lowest dosage before going down the next lowest dosage before that and so forth. This is the least sucky way to avoid problems when stopping any psychiatric medication. Presuming you have the option of slowly tapering off them.

How Topamax Works In Your Brain:  Topamax (topiramate) works using methods popular with anticonvulsants.  It just concentrates this activity in your temporal lobes.  That's the main reason why it's a wonder drug for some people and a cognitive nightmare for others.  If your temporal lobes aren't messed up (e.g. you don't experience flat-out rage, intense and frequent déjà vu and/or jamais vu, you smell things that aren't there or a host of other symptoms of temporal lobe dysfunction that a neurologist is often more qualified to determine than a psychiatrist) then Topamax may not be the right med for you.  Of course, that's just for epilepsy and bipolar.  When it comes to all the other off-label applications, I honestly don't have a clue.  What the temporal lobes have to do with those other disorders or where else Topamax is doing its thing - beats the hell out of me.

Anyway, here's what Topamax does for you:

• It messes with your calcium and sodium voltage channels.  Messing with voltage channels are one way anticonvulsants deal with reducing the hyperactivity in your brain that results in seizures and/or bipolar mood swings.

• It makes you really receptive to the GABA you have in your brain.  Not barbiturate-level receptive, but pretty damn receptive.  That's why it knocks you out and leaves you feeling pretty worn out all day.  It's also why it's an effective anticonvulsant and half-decent mood stabilizer.  GABA is a key neurotransmitter in quelling bipolar and epileptic hyperactivity.  It's also quite useful in dealing with various pain issues like migraines.

• It gets kainate to work on the glutamate receptor, but doesn't work on glutamate itself.  I'm not too clear on what kainate does for you.  Glutamate is a neurotransmitter that is getting a lot of study lately, not just as an anticonvulsant, but as an antidepressant and antipsychotic. 

• Finally it inhibits some isoenzymes of carbonic anhydrase (CA-II and CA-IV). Although not particularly strong in this regard and the floor is open to debate about how much it does for you when it comes to epilepsy and/or bipolar, it might be why some of the off-label applications work.   What I do know is that it's why you get kidney stones.  So check for this particular feature of any other drugs you might be taking, as that would dramatically increase your chances for kidney stones.

Chances Topamax Will Work and How Topamax Compares to Other Meds:  From the clinical trials of people suffering 60 or more seizure events a month.  About 40% adults with partial onset seizures taking 400-600mg of Topamax (topiramate) a day, along with another anticonvulsant, will see a 50% or better reduction in their seizure activity.  The average reduction in seizure activity is a little under 50%.

Kids with generalized tonic-clonic seizures and  Lennox-Gastaut Syndrome where given about 6mg  per kg.  So if you weighed around 150 pounds you'd get 400mg a day.  The dosages used were  125, 175, 225 and 400mg a day for the tonic-clonic seizures.  The average reduction in seizure activity was 56%, with 56% of the kids seeing their seizure activity at least cut in half.  The numbers weren't as good for Lennox-Gastaut, but with that syndrome any improvement is probably worth dealing with Topamax.

Here are the results from the clinical trials:

So the above results are good, if the trials were a bit small.  But you try finding people having two or more seizures a day who were willing to mess with their meds.

Comments:I would be dead, institutionalized, in jail or worse without the benefit of Topamax (topiramate). I'm one of the people that just loves Topamax (topiramate), despite the kidney stones and having it turn me into an idjit on psychiatric drugs. My seizure activity is gone, gone, gone. No more absence seizures (at least Mouse, the only person in the world kind enough to tell me when I was having the damn things, says I haven't been having any), no more simple partial events and no more rib-cracking, concussion-inducing, pants-wetting tonic-clonic grand mals. My bipolar activity is way under control. As long as I remember to take every dose every day I'm fine. If I forget a dose the results have been everything from a couple days of hypomania to a day-long mixed state. Topamax (topiramate)put an end to the violent, intrusive thoughts that Risperdal (risperidone) just wasn't able to handle alone. Topamax (topiramate)keeps me from punching holes through the walls of my house and smashing furniture, dishes and computer equipment into pieces.

Topamax (topiramate)is the key part of my cocktail, but it is an adjunctive medication. It works best in combination with other medications, although some people can get away with using it as monotherapy, for bipolar, epilepsy or whatever. There's been at least one small study using Topamax at lower dosages as monotherapy for epilepsy that showed it can be effective. More research needs to be done along those lines. The odds still are that in treating bipolar disorder and/or epilepsy, Topamax needs to be combined with another medication. This is usually because such problems do not reside entirely in one's temporal lobes, where Topamax does most of its work.

Unlike valproates such as Depakote (divalproex sodium) that also mess with your GABA, you don't want to eat more. Usually it's the opposite, it makes you want to eat less and even causes you to forget to eat! I need a schedule to eat meals.

This is why everyone clamors for Topamax - because of its weight-loss side effect, a side effect that not everyone gets. Sure, I've lost twenty pounds I could ill afford to lose since starting this med, but that side effect sucks less than the hell of ultradian rapid cycling, which Topamax has stopped dead in its tracks.  But it's not just me, there are studies out there showing Topamax to be effective for ultra-rapid cycling.  OK, we understand that weight is a big fucking deal for some people. Eating disorders, morbid obesity, dysmorphic body image and the societal pressure to be thin can depress the hell out of someone who has gained a shitload of weight thanks to Depakote (divalproex sodium), Remeron (mirtazapine) , Zyprexa (olanzapine)  or an SSRI. Besides all of the other side effects and the fact that Topamax may not even reduce your appetite, if you're on a medication that works, Topamax could fuck if up! Try something else first, please. If weight is seriously messing with your physical and mental health and you don't have symptoms of temporal lobe disorders, Topamax should be the weight loss treatment of last resort if your other drugs are working. Of course, if they're not working, then go ahead and try Topamax, it just might be the thing you need. Johnson & Johnson, the current owners of Topamax, began testing it as a weight loss medication on people without epilepsy, migraines or bipolar in 2002, but halted the tests because the side effects were too much for too many people. Oh, and if you try Topamax, then stop, then try it again, forget about losing weight with it. It's usually a one-time offer if you're going to get that at all.

Topamax is not for everyone, not just because of its other side effects, but because it hits your temporal lobes heavily, and the odds are your bipolar activity or epilepsy is not focused in your temporal lobes. This one extreme case illustrates the use of Topamax in bipolar disorder with temporal lobe dysfunction.  If you do have indications of temporal lobe disturbances, Topamax is usually best as an add-on medication. But for some people it can be effective as a primary mood stabilizer or antiepileptic. Besides the vaunted weight loss, Topamax is best known as Stupamax or Dopamax because it turns you into an idjit on drugs. It really is a supermodel drug that will make you skinny and stupid. Your memory will go down the toilet. You will experience mild aphasia, the inability to recall the correct word for something or calling something by a completely bizarre name. Your thinking will become fuzzy. And you had best drink lots of water, because Topamax is not extensively metabolized, is a weak carbonic anhydrase inhibitor, and is primarily cleared by your kidneys, so Topamax will give you a propensity for kidney stones. It gives me a couple small ones a year. I've found that trace mineral supplements and omega-3 fish oils helped to deal with the worst of the cognitive problems like the aphasia and stupid memory tricks I was getting until I hit the correct dosage.

For the first few months I was taking Topamax (topiramate) the intense and frequent déjà vu I experienced (one of the signs of temporal lobe damage) became jamais vu as the damage to the left lobe was being worked around. Jamais vu means the familiar will seem unfamiliar and out of place. Your stuff may not seem like it's your stuff for a few months. It may feel like people are moving your stuff around when that is not happening. I suggest not dusting to prove that nothing has been moved. Another weird effect is things seeming the wrong size. This will make grocery shopping a real adventure. So you come home with way too many carrots and not nearly enough potatoes, that's life on Topamax for your adjustment period. Really, those bizarre side effects just mean that the Topamax is working. Eventually it all gets straightened out and there's no more déjà vu and no more jamais vu and only French people get to see things in weird ways.

One thing that Topamax (topiramate)might be good for is stopping drinking. There's been one study done at the University of Texas in San Antonio on it as a way to deal with alcoholism that is very promising.¹ As I wrote above it's all added up that Ortho-McNeil paid for what looks like a full-on clinical trial to use Topamax to treat alcoholism.  Up to 300mg a day(!) decreased the number of heavy drinking days, drank less, and were abstinent longer.  This trial required the people be part of a support group (read: A.A. because that is what the people in the study were enrolled in). But there are some A.A. programs where all drugs are bad, including ones prescribed by psychiatrists to help one stop drinking and stay off the sauce because drinking was a form of self-medication!  300mg a day for outpatient A.A.? That's a crazy high dosage under those circumstances.  In the study people who dropped out were considered to have relapsed.  OK, but what happened to those people?  The people doing the study tested for withdrawal symptoms, but withdrawal from what?  Alcohol?  Topamax?  Either?  Of the 183 people receiving Topamax, 13 were "lost to follow-up."   I.e. they never returned to the clinic.  At what dosage?  Did they just stop taking the Topamax?  Did they do that and drink heavily?  That's 7% of the people taking Topamax, anything could have happened to them.

Don't get me wrong, I'm all for using Topamax as a drug to stop people from drinking themselves to death.  I'm all for Ortho-McNeil doing trials to get Topamax approved for this, even if it does mean a patent extension that keeps Topamax from going generic for a couple more years.  What I don't like is this being done in an outpatient setting.  It's too dangerous.  People can die, and the ramifications extend to those of us who have been taking Topamax for long-approved applications.  All the people taking it for off-label applications can really be up the creek.

There has also been one study done and another underway for its use in treating PTSD. Given how Topamax messes with your memory, that just makes so much sense.

Like Lamictal (lamotrigine), Topamax (topiramate)can cause a lot of muscle aches and pains, despite also being good for them.  I have a guess as to what that is about.  Topamax is one of the few meds approved for Lennox-Gastaut syndrome, an uncommon form of epilepsy that, among other symptoms, presents the atonic seizure, where all your muscles go utterly limp.  You're having yet another relationship argument and you fall into a big pile of being the human turd, unable to move or even look away from the stain on the carpet.  I've been there with the atonic seizures.  I don't know how Topamax (topiramate)rates when compared to Lamictal (lamotrigine) for Lennox-Gastaut, but they both have FDA approval to treat the disorder.  So if you've got a med that keeps your muscles from going limp and normally your muscles don't go limp all the time, it would follow that muscle aches and pains could be a result.

However, there is some good news on the skin front.  It seems that Topamax (topiramate)can be good for your skin in one way, it appears to old scars heal.  OK, so I've checked my old scars.  The most noticeable is, of course, even more noticeable now.  Good old paradoxical reaction there.  But many others do appear to be vanishing.  Now I'm not a good test subject for this, as I don't get much in the way of scarring and even my tattoo began to fade long before I took Topamax.  Yet the scars I did have before weren't going away, so there may be something here after all.

Topamax (topiramate)is a medication that people either love or hate, there is very little middle ground with this drug. One of the problems is that the side effects, especially the cognitive effects, are very dosage dependent. The weird thing is, while they can start to get better when you acclimate to a lower dosage that you're on and then come back when you move up to a higher dosage, very often it's not until you hit the sweet spot that they finally get to the point where they aren't so bad. So they can suck and suck and suck as you work your way up to a particular dosage, then suddenly they aren't that bad, then they get bad again if you start taking too much! The main problem is too many psychiatrists will throw Topamax at somebody, perhaps just to shut them up about the ten pounds they gained because of some other drug, without evaluating them for any temporal lobe dysfunction. And if Topamax hits a pair of healthy temporal lobes, watch out! It's usually all side effects and rarely any benefit. That's where all the hating comes from. The side effects never go away, they probably suck worse than for people who do have temporal lobe issues, and there's never any positive results. Once I put it up, check out the article on recognizing the signs of temporal lobe dysfunction to see if Topamax would be a good fit for your bipolar. I'd presume that a neurologist would be on top of all of this, even though the older EEGs were often crap when it came to picking up problems in the temporal lobes. One neurologist I saw was able to determine I had temporal lobe issues based upon the way I walked and a reflex reaction I had in my feet, in addition to some of the items I'll be explaining to you.

As this keeps coming up, I think I had better explain the kidney stone thing a bit more.

One question frequently asked is if the risk of kidney stones increases with the dosage of Topamax (topiramate)?

That's a good question, I wish I had a good answer. There just aren't enough data to know if the kidney stone problem is dosage-dependent. The clinical trials and studies for Topamax were done with people taking 200-1,000mg a day. 1.5% of the people taking Topamax during various trials and studies run by Ortho-McNeil developed kidney stones, running 4 times higher than expected for people not taking any meds.

Here are the factors that put you at risk, and what made it pretty damn obvious that I was going to get them no matter what.

1) Men got them more than women (check)

2) You're on one of those trendy high-protein diets (wacky food allergies force me to eat more protein than carbs, check)

3) Family history (Hell, I had a prior history of kidney stones)

4) Taking other carbonic anhydrase inhibitors (the only thing I'm not doing - I think - I haven't delved into this aspect of all the other meds in my cocktail)

I was pretty much destined for kidney stones with Topamax. That's why I started drinking 2-3 liters of water a day after I began taking it. As always it comes down to which is going to suck less? In this case the kidney stones, such as they are, suck way less than what I was going through before Topamax.

So if you have just one of the above risk factors, the chances of developing kidney stones are low.  If you have two or more then you and your doctor have to figure out if the risk of the stones is going to be worth the benefits of Topamax.     You can take prophylactic measures if you do fall into one of the high-risk categories.

1) If you're a guy there's not much you can do about that.  Well, there is, but I don't think The Operation is worth doing because of a medication.

2) Topamax and the Atkins or South Beach diets don't mix.  High protein diets make your kidneys work harder.  Topamax makes your kidneys work harder.  Your kidneys can usually deal with one or the other without too many problems, but doing both is pushing it.  If you're in this to lose weight, pick one or the other.  Don't do both to drop a lot of weight fast.  Really fast weight loss isn't good for you anyway.  If you're like me and you have wacky food allergies that forces you onto a low carbohydrate diet just because most grains will make you ill, that's another story.   But if you have the option to eat lots of carbs, you'll want to reduce your protein intake with Topamax if you're concerned about kidney stones.  With the revised (12/30/2003) PI sheet it turns out that high protein/low carb diets and Topamax also increase the risk for osteoporosis.  Yow!  From an seizure-control standpoint a true ketogenic diet is something that is often tried with some success.  But you may want to think twice about mixing it with Topamax.  I wouldn't be eating like I do were it not for my food allergies.

3) You also can't do much about family or personal history.

4) As for other carbonic anhydrase inhibitors, that all depends on what other medical issues you have and what other options are available.

My advice - if the benefits are there, drink 2-3 liters of water a day and reduce the amount of protein, salt and high oxalate foods you eat, if possible.  Here's a great site for more information on the cause & prevention of kidney stones, regardless of their origin.

If you do develop a stone, it probably won't be as bad as it could have been, then you can reevaluate continuing with Topamax.  The stones I get now are nothing compared to the stones I got before Topamax, because I planned for the possibility of more of the little buggers.  They form, I notice them, I drink even more water  and I can't even tell when they pass because they've dissolved into nothingness.

Have questions about Topamax?  Want to read about experiences other people have had with Topamax? Check out our Topamax Board.

Who Makes Topamax: Ortho-McNeil and Janssen-Cilag, subsidiaries of Johnson & Johnson

Sample US Cost of Topamax: $242 for 60 100mg tablets.

As of 11/19/2003. Full retail for the uninsured. Go ahead and gloat, citizens of civilized countries and all of you with full medical coverage.

Sample Canadian Cost of Topamax: $146 for 60 100mg tablets.

Remedy Find Rating of Topamax for Migraines

Remedy Find Rating of Topamax for Bipolar Disorder

Check for Drug-Drug Interactions

Full US Prescribing/Physician Information Sheet or Package Insert or whatever PI stands for.  It's for the doctors, but you may get one by accident.

UK Summary of Product Characteristics (SPC) for doctors.

UK Patient Information Literature (PIL)

New Zealand Data Sheet for doctors.

South African Package Insert for patients.

French Epitomax PI Sheet - Looks half-way between the UK SPC and PIL, so it's either for less-informed doctors or somewhat more informed patients.

Greek Topamac Sheet  For patients or physicians, I'm clueless, as it's all Greek to me.

Egyptian PI Sheet  For doctors, in English.

Russian Топамакс (Topamax)  Sheet  From Recipe.ru.  It's in Cyrillic.  Damned if I know the audience for this one.

Israeli Topamax PI sheet For doctors, in English.

Argentinean Topamac PI sheet - For doctors, in Spanish.

Taiwanese Topamax Patient Information Leaflet in traditional Chinese characters.  The Taiwanese PI sheets are the worst on the planet for the dearth of information they provide.

Please see the section on how to read these sheets. Don't freak out about every potential side effect. Look at the odds of something having happened during the clinical trials.

Wikipedia Topamax entry