Is it necessary for a patient taking topiramate (an antiepileptic medication) 50 mg twice daily for weight control to discontinue it two weeks prior to a deep plane face lift?

Topiramate Discontinuation Before Deep Plane Face Lift

There is no established medical indication to discontinue topiramate 50 mg twice daily two weeks prior to a deep plane face lift for a patient using it for weight control. The available evidence does not identify topiramate as a medication requiring perioperative cessation for cosmetic or reconstructive facial surgery.

Rationale for Lack of Discontinuation Requirement

Pharmacological Profile

• Topiramate has a favorable pharmacokinetic profile with rapid absorption, good bioavailability, linear pharmacokinetics, and a relatively long half-life, but these properties do not create specific surgical contraindications 1
• The medication's mechanisms of action—GABA potentiation, glutamate receptor impairment, and suppression of high-frequency action potential firing—do not interfere with anesthesia or wound healing 1

Perioperative Considerations

• The primary concern with abrupt topiramate discontinuation is the risk of precipitating seizures, particularly in patients using it for epilepsy, though this patient is using it for weight control 2
• If discontinuation were medically necessary, proper tapering protocol requires taking one capsule every other day for at least one week before stopping completely to avoid seizure risk 2
• A two-week cessation period followed by resumption would be inappropriate given the gradual titration requirements for topiramate 2

Common Pitfalls and Likely Explanation

Why the Provider May Be Requesting This

The surgeon may be concerned about:

• Bleeding risk: However, topiramate is not associated with coagulopathy or increased surgical bleeding
• Drug interactions with anesthesia: Topiramate does not have clinically significant interactions with standard anesthetic agents 1
• Carbonic anhydrase inhibition effects: While topiramate inhibits carbonic anhydrase, this does not create perioperative complications for facial surgery 3

What Should Actually Be Addressed

• Blood pressure and heart rate monitoring is important given the phentermine component if the patient were on combination phentermine/topiramate, but this patient appears to be on topiramate monotherapy at 50 mg twice daily 2
• Standard perioperative medication reconciliation should focus on anticoagulants, antiplatelet agents, and medications that truly affect surgical outcomes

Clinical Recommendation

Continue topiramate 50 mg twice daily through the perioperative period without interruption. The patient should:

• Inform the anesthesiologist about topiramate use during preoperative assessment
• Maintain adequate hydration perioperatively, as topiramate can be associated with metabolic acidosis in rare cases 3
• Resume normal dosing schedule immediately postoperatively

If the surgeon insists on discontinuation despite lack of evidence, request specific documentation of the clinical rationale, as this represents a deviation from standard perioperative medication management and creates unnecessary risk of medication discontinuation complications without clear benefit to surgical outcomes.