From the Guidelines
Topamax (topiramate) is contraindicated in patients with pregnancy and breastfeeding due to its teratogenicity, as well as in those with glaucoma, severe hepatic impairment, and hyperthyroidism. The medication should be used with caution in patients with kidney stones, as it can increase the risk of kidney stone formation due to its carbonic anhydrase inhibition properties 1. Additionally, topiramate should be used carefully with other CNS depressants as it may enhance sedation effects, and patients with a history of suicidal thoughts or behavior require close monitoring as topiramate may increase suicide risk 1.
Some of the key contraindications and precautions for topiramate include:
- Pregnancy and breastfeeding due to teratogenicity 1
- Glaucoma, particularly acute angle-closure glaucoma 1
- Severe hepatic impairment 1
- Hyperthyroidism 1
- Seizure disorder, as topiramate can lower the seizure threshold 1
- Dose adjustment with hepatic or renal impairment 1
- Combined use with alcohol or depressant drugs can worsen cognitive impairment 1
- Concomitant use with MAOI (allow ≥14 days between discontinuation) 1
It is essential to monitor patients taking topiramate for potential side effects, including:
- Cognitive impairment, such as confusion and difficulty concentrating 1
- Decreased sweating and increased body temperature, potentially leading to hyperthermia 1
- Kidney stone formation due to its carbonic anhydrase inhibition properties 1
- Electrolyte imbalance, particularly hypokalemia 1
- Suicidal ideation and behavior 1
Overall, topiramate should be used with caution and under close monitoring in patients with certain medical conditions, and its potential benefits and risks should be carefully weighed before initiating treatment 1.
From the FDA Drug Label
Topiramate is contraindicated in patients with a history of hypersensitivity to any component of this product. The main contraindication for topamax is a history of hypersensitivity to any component of the product 2.
- Key contraindication: Hypersensitivity to topiramate or its components.
From the Research
Contraindications with Topamax
- Topamax can cause nephrolithiasis, a condition characterized by the formation of kidney stones, due to its inhibition of renal carbonic anhydrase, leading to renal tubular acidosis and hypercalciuria 3, 4, 5, 6
- The risk of nephrolithiasis is increased in children with baseline hypercalciuria, and greater urinary calcium excretion is associated with increasing doses of topiramate 3
- Topamax can also cause metabolic acidosis, hypokalaemia, and hyperuricaemia, which can increase the risk of renal stone formation 7, 5, 6
- The use of topiramate is linked with a tendency towards mild-to-moderate hyperchloraemic metabolic acidosis and mild hypokalaemia, as well as hypocitraturia, a recognized promoter of renal stone formation 5
- Patients treated with topiramate should have baseline and follow-up urinary calcium/creatinine studies, serum electrolytes, and periodic renal ultrasonography to monitor for potential contraindications 3
Specific Contraindications
- Nephrolithiasis and nephrocalcinosis, which can be caused by topiramate's inhibition of renal carbonic anhydrase 3, 4
- Metabolic acidosis, which can be caused by topiramate's inhibition of renal carbonic anhydrase 5, 6
- Hypokalaemia, which can be caused by topiramate's effects on potassium balance 5
- Hyperuricaemia, which can be caused by topiramate's effects on uric acid metabolism 5
Patient Populations at Risk
- Children with epilepsy, who may be at increased risk of nephrolithiasis and metabolic acidosis due to topiramate treatment 3, 4
- Patients with a history of kidney stones or nephrocalcinosis, who may be at increased risk of recurrent stone formation due to topiramate treatment 6
- Patients with conditions that reduce mobility, who may be at increased risk of nephrolithiasis due to topiramate treatment 4