Topiramate for Alcohol Use Disorder (AUD)

"Although not FDA approved for AUD, the anticonvulsant topiramate can be used for treatment of AUD. Like acamprosate, topiramate is thought to modulate GABA and glutamate transmission. A 2023 meta-analysis of 8 double-blind RCTs (N = 1080) with treatment duration of at least 12 weeks reported a significant reduction in the absolute percentage of drinking days with topiramate compared with placebo (weighted mean difference, −7.2% [95% CI, −14.3% to −0.1%]) and a reduction in the average number of drinks per day (weighted mean difference, −2.0 [95% CI, −3.1 to −1.0]).4 Topiramate requires slow upward titration to treatment doses (100 to 150 mg twice daily) over 6 to 8 weeks to prevent self-limited neurologic effects, such as paresthesia (0%-57.3% with topiramate, 1.9%-29.4% with placebo), dysgeusia (taste disorder; 15.1%-53.3% with topiramate, 4.8%-31.3% with placebo), and cognitive dysfunction (12.6%-23.9% with topiramate, 5.4%-11.3% with placebo). The need for slow titration and common cognitive effects often limit use of topiramate."