Medication Reference Card — Alcohol Use Disorder
Titrate to 75–200 mg/day · Slow titration essential · Off-label (AUD)
Topiramate is an epilepsy medication with good evidence for reducing alcohol use. It is particularly helpful for people who also experience anxiety, PTSD symptoms, or other mental health challenges alongside their drinking. It is started at a low dose and increased gradually to minimise side effects.
Multiple mechanisms: AMPA/kainate glutamate receptor antagonism, GABA-A facilitation, sodium and calcium channel blockade. Net effect: reduces dopaminergic reward from alcohol and dampens limbic hyperactivity. Also reduces cortisol response to stress — basis for PTSD benefit.
Titration schedule: 25 mg/day, increasing by 25 mg each week over 8 weeks to target 75–200 mg/day. Slow titration is essential to reduce cognitive side effects ("Dopamax" effect). Off-label for AUD in Australia — document rationale and obtain consent.
Once-daily dosing (nocte) is a reasonable clinical option — topiramate t½ ~21 h supports once-daily administration and taking the dose at night may reduce daytime cognitive burden. No AUD RCT has formally compared once-daily versus twice-daily regimens.
Moderate-to-good evidence across a range of doses. Johnson et al. JAMA 2007: 300 mg/day significantly reduced heavy drinking days and improved abstinence vs placebo. Kranzler et al. Am J Psychiatry 2024: 200 mg/day was equivalent to or better than naltrexone in a genotype-stratified RCT. Blodgett et al. BMC Psychiatry 2011: low-dose (mean ~55 mg/day, target 75 mg/day) produced a 56% reduction in relapse risk vs psychotherapy alone. Evidence supports efficacy across a dose range of 75–300 mg/day, with lower doses generally better tolerated.