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topiramate

(toe pie' rah mate)


Topamax

Pregnancy Category C

Drug class
Antiepileptic

Therapeutic actions
Mechanism of action not understood; antiepileptic effects may be due to the actions of
blocking sodium channels in neurons with sustained depolarization; increasing GABA
activity at receptors, thus potentiating the effects of this inhibitory neurotransmitter; and
blocking excitatory neurotransmitters at neuron receptor sites.

Indications
• Adjunctive therapy for partial-onset seizure treatment in adults and children 2–16
yr
• Adjunctive therapy for seizures associated with Lennox-Gastaut syndrome in
adults and children
• Adjunctive therapy for primary generalized tonic-clonic seizures in adults and
children 2–16 yr
• Unlabeled uses: Cluster headaches, infantile spasms

Contraindications and cautions


• Contraindicated with hypersensitivity to any component of the drug.
• Use cautiously with pregnancy (use only if benefits outweigh potential risks to
fetus), lactation, renal or hepatic impairment, renal stones.

Available forms
Tablets—25, 100, 200 mg; sprinkle capsules—15, 25 mg

Dosages
ADULTS
400 mg PO daily in 2 divided doses; begin adjustment of dose at 25–50 mg/day in the
evening for wk 1; 50 mg AM and PM for wk 2; 50 mg AM and 100 mg PM for wk 3;
100 mg AM and PM for wk 4; 100 mg AM and 150 mg PM for wk 5; 150 mg AM and
PM for wk 6; 150 mg AM and 200 mg PM for wk 7; and 200 mg AM and PM for wk 8
and beyond.
PEDIATRIC PATIENTS 2–16 YR
5–9 mg/kg/day PO in 2 divided doses, as adjunctive therapy for Lennox-Gastaut
syndrome; begin therapy at < 25 mg and increase in increments of 1–3 mg/kg/day every
1–2 wk.
PATIENTS WITH RENAL OR HEPATIC IMPAIRMENT
For creatinine clearance < 70 mL/min, use one-half the usual dose; allow increased time
to reach desired level. For patients with hepatic impairment, adjust slowly; monitor
patient carefully.

Pharmacokinetics
Route Onset Peak
Oral Rapid 2 hr
Metabolism: Hepatic; T1/2: 21 hr
Distribution: Crosses placenta; enters breast milk
Excretion: Urine

Adverse effects
• CNS: Ataxia, somnolence, dizziness, nystagmus, nervousness, anxiety, tremor,
speech impairment, paresthesias, confusion, depression
• GI: Nausea, dyspepsia, anorexia, vomiting
• GU: Dysmenorrhea
• Hematologic: Leukopenia
• Respiratory: Upper respiratory infection, pharyngitis, sinusitis
• Other: Fatigue, rash, acute myopia and secondary angle-closure glaucoma (pain,
visual disturbances, pupil dilation, redness, increased IOP), weight loss

Interactions
Drug-drug
• Increased CNS depression if taken with alcohol or CNS depressants; use extreme
caution
• Increased risk of renal stone development with carbonic anhydrase inhibitors
• Decreased effects of hormonal contraceptives with topiramate; suggest use of
barrier contraceptives instead

Nursing considerations
CLINICAL ALERT!
Name confusion has occurred between Topamax and Toprol-XL
(metoprolol); use caution.

Assessment
• History: Hypersensitivity to any component of the drug; pregnancy, lactation;
renal or hepatic impairment; renal stones
• Physical: Skin color, lesions; orientation, affect, reflexes, vision exam; R,
adventitious sounds; liver and renal function tests

Interventions
• Reduce dosage; discontinue or substitute other antiepileptic gradually; abrupt
discontinuation may precipitate status epilepticus.
• Stop the drug immediately and arrange for appropriate consultations at first sign
of blurred vision, periorbital edema, or redness.
• Administer with food if GI upset occurs.
• Caution patient not to chew or break tablets because of bitter taste.
• Have patient swallow sprinkle capsules whole or by carefully opening capsule
and sprinkling onto a soft food. Swallow this immediately; do not allow it to be
chewed.
• Encourage patients with a history of renal stone development to maintain
adequate fluid intake while using this drug.
• Suggest using barrier contraceptives to patients taking this drug.
• Arrange for consultation with appropriate epilepsy support groups as needed.

Teaching points
• Take this drug exactly as prescribed. Do not break or chew tablets; they have a
very bitter taste. If using sprinkle capsules, open carefully and sprinkle onto soft
food and swallow immediately; do not chew.
• Do not discontinue this drug abruptly or change dosage except on the advice of
your health care provider.
• Arrange for frequent check-ups to monitor your response to this drug. It is very
important that you keep all appointments for check-ups.
• Wear a medical alert bracelet at all times so that any emergency medical
personnel will know that you have epilepsy and are taking antiepileptic
medication.
• Avoid using alcohol while you are taking this drug; serious sedation could occur.
• These side effects may occur: Drowsiness, dizziness, sleepiness (avoid driving or
performing other tasks that require alertness; symptoms may occur initially but
usually disappear with continued therapy); vision changes (avoid performing
tasks that require visual acuity); GI upset (take drug with food; eat frequent small
meals).
• Report fatigue, vision changes, speech problems, personality changes.

Adverse effects in Italic are most common; those in Bold are life-threatening.