Topiramate for Binge Eating Disorder
Topiramate is an effective treatment option for binge eating disorder, showing significant reduction in binge episodes and associated weight loss, though it is not FDA-approved for this indication. 1
Efficacy of Topiramate in Binge Eating Disorder
Topiramate has demonstrated promising results in treating binge eating disorder through several mechanisms:
- It reduces food intake by modulating gamma-aminobutyric acid receptors
- Inhibits carbonic anhydrase
- Antagonizes glutamate to decrease appetite and increase satiation 1
Recent evidence from the 2025 Circulation Research guideline indicates that topiramate is among the effective anticonvulsants for treating binge eating disorder, which is particularly prevalent in women and can be exacerbated in those with conditions like PCOS 1.
Dosing and Administration
For binge eating disorder treatment:
- Starting dose: 25-50 mg/day
- Gradually titrate upward based on response and tolerability
- Effective dose range: 100-400 mg/day (median effective dose in studies: ~212 mg/day) 2
- Consider divided dosing to improve tolerability
Clinical Evidence
The most recent high-quality evidence from a 2025 network meta-analysis found that:
- Topiramate showed the greatest efficacy for reducing binge-eating episodes (mean difference = -1.72) compared to other medications
- It had the highest remission rates (odds ratio = 3.99) among studied medications
- It outperformed even lisdexamfetamine (which is FDA-approved for BED) in efficacy measures 3
Earlier randomized controlled trials demonstrated:
- 94% reduction in binge frequency (vs. 46% with placebo)
- 93% reduction in binge day frequency (vs. 46% with placebo)
- Mean weight loss of 5.9 kg in completers 2
Combination Therapy
Phentermine-topiramate extended-release (Qsymia) has shown efficacy for both weight loss and binge eating symptoms:
- Available in 4 doses: 3.75/23 mg, 7.5/46 mg, 11.25/69 mg, and 15/92 mg
- Gradual dose escalation recommended
- Should be discontinued if 3% weight loss is not achieved after 12 weeks at 7.5/46 mg daily 1, 4
Side Effects and Monitoring
Common side effects include:
- Paresthesias
- Dysgeusia (altered taste)
- Cognitive impairment
- Dry mouth
- Constipation
- Insomnia 1
Important monitoring considerations:
- Monitor serum bicarbonate levels (due to carbonic anhydrase inhibition)
- Assess for kidney stone risk (hypercalciuria and hypocitraturia)
- Screen for mood changes, especially in patients with bipolar disorder 5
Special Considerations
Caution in specific populations:
- Women of childbearing potential: Topiramate is teratogenic. Effective contraception is essential 1
- Patients with bipolar disorder: Case reports indicate topiramate may precipitate manic episodes in bipolar patients 5
- Patients with history of kidney stones: Increased risk due to carbonic anhydrase inhibition
Advantages for specific populations:
- Patients with comorbid migraines: Topiramate is FDA-approved for migraine prophylaxis 1
- Patients with obesity: Produces significant weight loss in addition to binge eating control 2
Clinical Pearls
- Take topiramate early in the day to minimize insomnia
- Start low and titrate slowly to minimize side effects
- Consider combination with mood stabilizers in patients with bipolar disorder
- Monitor for cognitive side effects, which may limit dose escalation
- Discontinue if inadequate response after 12 weeks at maximum tolerated dose
While lisdexamfetamine is the only FDA-approved medication specifically for BED, topiramate represents an effective alternative, particularly for patients who cannot tolerate stimulants or who have comorbid conditions like migraines that might benefit from topiramate's effects.