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Topiramate Dosage

Medically reviewed on January 18, 2018.

Applies to the following strengths: 25 mg; 50 mg; 100 mg; 200 mg; 15 mg; 150 mg

Usual Adult Dose for Epilepsy

MONOTHERAPY:
Immediate-Release: 400 mg orally daily in 2 divided doses
-The dose should be achieved by titration according to the following schedule:
Week 1: 25 mg orally in the AM and 25 mg orally in the PM
Week 2: 50 mg orally in the AM and 50 mg orally in the PM
Week 3: 75 mg orally in the AM and 75 mg orally in the PM
Week 4: 100 mg orally in the AM and 100 mg orally in the PM
Week 5: 150 mg orally in the AM and 150 mg orally in the PM
Week 6: 200 mg orally in the AM and 200 mg orally in the PM

Extended-Release: 400 mg orally once a day
-The dose should be achieved by titration according to the following schedule:
Week 1: 50 mg once a day
Week 2: 100 mg once a day
Week 3: 150 mg once a day
Week 4: 200 mg once a day
Week 5: 300 mg once a day
Week 6: 400 mg once a day

ADJUNCTIVE THERAPY:
Immediate-Release:
-Partial onset seizures: 200 to 400 mg orally daily in 2 divided doses
-Primary generalized tonic-clonic seizures: 400 mg orally daily in 2 divided doses
The dose should be achieved by titration: Initiate with 25 to 50 mg orally once a day; increase in increments of 25 to 50 mg orally daily every week to an effective dose.

Extended-Release:
-Partial onset seizures: 200 to 400 mg orally once a day
-Primary generalized tonic-clonic seizures: 400 mg orally once a day
The dose should be achieved by titration: Initiate therapy at 25 to 50 mg orally once a day followed by titration in increments of 25 to 50 mg every week to an effective dose.

Comments:
-Doses above 400 mg daily have not been shown to improve responses in dose-response studies in adults with partial onset seizures.
-Daily topiramate doses above 1600 mg have not been studied.
-Co-administration with phenytoin and/or carbamazepine may require dose adjustments.

Uses:
-Initial monotherapy or adjunctive therapy for patients with partial onset or primary generalized tonic-clonic seizures.

Usual Adult Dose for Migraine Prophylaxis

IMMEDIATE RELEASE: 100 mg daily in 2 divided doses
The dose should be achieved by titration:
Week 1: No dose in the AM and 25 mg orally in the PM
Week 2: 25 mg orally in the AM and 25 mg orally in the PM
Week 3: 25 mg orally in the AM and 50 mg orally in the PM
Week 4: 50 mg orally in the AM and 50 mg orally in the PM

EXTENDED-RELEASE: 100 mg orally once a day
The dose should be achieved by titration:
Week 1: 25 mg orally once a day
Week 2: 50 mg orally once a day
Week 3: 75 mg orally once a day
Week 4: 100 mg orally once a day

Comments:
-Dose titration rate should be guided by clinical outcome, if needed, longer intervals between dose adjustments may be used.

Use: For the prophylaxis of migraine headache

Usual Adult Dose for Lennox-Gastaut Syndrome

ADJUNCTIVE THERAPY:

Immediate-Release: 200 to 400 mg orally daily in 2 divided doses
-Initiate with 25 to 50 mg orally once a day; increase in increments of 25 to 50 mg orally daily every week to an effective dose.

Extended-Release: 200 to 400 mg orally once a day
-Initiate therapy at 25 to 50 mg orally once a day followed by titration in increments of 25 to 50 mg every week to an effective dose.

Comments:
-Doses above 400 mg daily have not been shown to improve responses in dose-response studies in adults with partial onset seizures.
-Daily topiramate doses above 1600 mg have not been studied.
-Co-administration with phenytoin and/or carbamazepine may require dose adjustments.

Use: Adjunctive therapy for patients with seizures associated with Lennox-Gastaut syndrome (LGS).

Usual Pediatric Dose for Epilepsy

MONOTHERAPY:
2 to less than 10 years old:
IMMEDIATE-RELEASE:
-Week 1: 25 mg orally once a day in the evening
-If tolerated, increase to 25 mg orally 2 times a day for Week 2
-Thereafter, increase by 25 to 50 mg/day each week as tolerated.
-Titration to the minimum maintenance dose should be attempted over 5 to 7 weeks; based upon tolerability and clinical response, titration to a higher dose (up to the maximum maintenance dose) can be attempted weekly in increments of 25 to 50 mg/day.
-Maintenance dose (administered in 2 equally divided doses):
Up to 11 kg: Minimum: 150 mg/day; Maximum: 250 mg/day
12 to 22 kg: Minimum: 200 mg/day; Maximum: 300 mg/day
23 to 31 kg: Minimum: 200 mg/day; Maximum: 350 mg/day
32 to 38 kg: Minimum: 250 mg/day; Maximum: 350 mg/day
Greater than 38 kg: Minimum: 250 mg/day; Maximum: 400 mg/day
EXTENDED-RELEASE:
-Week 1: 25 mg orally once a day in the evening
-If tolerated, increase to 50 mg orally once a day for Week 2
-Thereafter, increase by 25 to 50 mg/day each week as tolerated.
-Titration to the minimum maintenance dose should be attempted over 5 to 7 weeks; based upon tolerability and clinical response, titration to a higher dose (up to the maximum maintenance dose) can be attempted weekly in increments of 25 to 50 mg/day.
-Maintenance dose (administered once a day):
Up to 11 kg: Minimum: 150 mg/day; Maximum: 250 mg/day
12 to 22 kg: Minimum: 200 mg/day; Maximum: 300 mg/day
23 to 31 kg: Minimum: 200 mg/day; Maximum: 350 mg/day
32 to 38 kg: Minimum: 250 mg/day; Maximum: 350 mg/day
Greater than 38 kg: Minimum: 250 mg/day; Maximum: 400 mg/day

10 years or older:
IMMEDIATE-RELEASE: 400 mg orally daily in 2 divided doses
-The dose should be achieved by titration according to the following schedule:
Week 1: 25 mg orally in the AM and 25 mg orally in the PM
Week 2: 50 mg orally in the AM and 50 mg orally in the PM
Week 3: 75 mg orally in the AM and 75 mg orally in the PM
Week 4: 100 mg orally in the AM and 100 mg orally in the PM
Week 5: 150 mg orally in the AM and 150 mg orally in the PM
Week 6: 200 mg orally in the AM and 200 mg orally in the PM
EXTENDED-RELEASE: 400 mg orally once a day
-The dose should be achieved by titration according to the following schedule:
Week 1: 50 mg once a day
Week 2: 100 mg once a day
Week 3: 150 mg once a day
Week 4: 200 mg once a day
Week 5: 300 mg once a day
Week 6: 400 mg once a day

ADJUNCTIVE THERAPY:
2 to 16 years old:
IMMEDIATE-RELEASE: 5 to 9 mg/kg in 2 divided doses
The dose should be achieved by titration:
-Initiate with 25 mg orally once a day (or less, based on range of 1 to 3 mg/kg/day); increase in increments of 1 to 3 mg/kg/day (in divided doses twice a day) every 1 or 2 weeks to an effective dose.
Maximum daily dose: 400 mg/day
EXTENDED-RELEASE: 5 to 9 mg/kg/day
The dose should be achieved by titration:
-Initiate with 25 mg orally once a day (based on range of 1 to 3 mg/kg/day); increase in increments of 1 to 3 mg/kg/day every 1 or 2 weeks to an effective dose.
Maximum daily dose: 400 mg/day

17 years or older: See Adult Dosing

Comments:
-Qudexy XR (R): Extended-release capsules may be swallowed whole or opened and sprinkled on a spoonful of soft food. These extended-release capsules are appropriate for pediatric patients 2 years or older.
-Trokendi XR(R): Extended-release capsules must be swallowed whole and intact and therefore are not appropriate for children less than 6 years of age.
-Dose titration should be guided by clinical outcome.
-Co-administration with phenytoin and/or carbamazepine may require dose adjustments.

Uses:
-Initial monotherapy in patients 2 years or older with partial onset or primary generalized tonic-clonic seizures, and as adjunctive therapy for patients with partial onset or primary generalized tonic-clonic seizures or seizures associated with Lennox-Gastaut syndrome.

Usual Pediatric Dose for Lennox-Gastaut Syndrome

MONOTHERAPY:
2 to less than 10 years old:
IMMEDIATE-RELEASE:
-Week 1: 25 mg orally once a day in the evening
-If tolerated, increase to 25 mg orally 2 times a day for Week 2
-Thereafter, increase by 25 to 50 mg/day each week as tolerated.
-Titration to the minimum maintenance dose should be attempted over 5 to 7 weeks; based upon tolerability and clinical response, titration to a higher dose (up to the maximum maintenance dose) can be attempted weekly in increments of 25 to 50 mg/day.
-Maintenance dose (administered in 2 equally divided doses):
Up to 11 kg: Minimum: 150 mg/day; Maximum: 250 mg/day
12 to 22 kg: Minimum: 200 mg/day; Maximum: 300 mg/day
23 to 31 kg: Minimum: 200 mg/day; Maximum: 350 mg/day
32 to 38 kg: Minimum: 250 mg/day; Maximum: 350 mg/day
Greater than 38 kg: Minimum: 250 mg/day; Maximum: 400 mg/day
EXTENDED-RELEASE:
-Week 1: 25 mg orally once a day in the evening
-If tolerated, increase to 50 mg orally once a day for Week 2
-Thereafter, increase by 25 to 50 mg/day each week as tolerated.
-Titration to the minimum maintenance dose should be attempted over 5 to 7 weeks; based upon tolerability and clinical response, titration to a higher dose (up to the maximum maintenance dose) can be attempted weekly in increments of 25 to 50 mg/day.
-Maintenance dose (administered once a day):
Up to 11 kg: Minimum: 150 mg/day; Maximum: 250 mg/day
12 to 22 kg: Minimum: 200 mg/day; Maximum: 300 mg/day
23 to 31 kg: Minimum: 200 mg/day; Maximum: 350 mg/day
32 to 38 kg: Minimum: 250 mg/day; Maximum: 350 mg/day
Greater than 38 kg: Minimum: 250 mg/day; Maximum: 400 mg/day

10 years or older:
IMMEDIATE-RELEASE: 400 mg orally daily in 2 divided doses
-The dose should be achieved by titration according to the following schedule:
Week 1: 25 mg orally in the AM and 25 mg orally in the PM
Week 2: 50 mg orally in the AM and 50 mg orally in the PM
Week 3: 75 mg orally in the AM and 75 mg orally in the PM
Week 4: 100 mg orally in the AM and 100 mg orally in the PM
Week 5: 150 mg orally in the AM and 150 mg orally in the PM
Week 6: 200 mg orally in the AM and 200 mg orally in the PM
EXTENDED-RELEASE: 400 mg orally once a day
-The dose should be achieved by titration according to the following schedule:
Week 1: 50 mg once a day
Week 2: 100 mg once a day
Week 3: 150 mg once a day
Week 4: 200 mg once a day
Week 5: 300 mg once a day
Week 6: 400 mg once a day

ADJUNCTIVE THERAPY:
2 to 16 years old:
IMMEDIATE-RELEASE: 5 to 9 mg/kg in 2 divided doses
The dose should be achieved by titration:
-Initiate with 25 mg orally once a day (or less, based on range of 1 to 3 mg/kg/day); increase in increments of 1 to 3 mg/kg/day (in divided doses twice a day) every 1 or 2 weeks to an effective dose.
Maximum daily dose: 400 mg/day
EXTENDED-RELEASE: 5 to 9 mg/kg/day
The dose should be achieved by titration:
-Initiate with 25 mg orally once a day (based on range of 1 to 3 mg/kg/day); increase in increments of 1 to 3 mg/kg/day every 1 or 2 weeks to an effective dose.
Maximum daily dose: 400 mg/day

17 years or older: See Adult Dosing

Comments:
-Qudexy XR (R): Extended-release capsules may be swallowed whole or opened and sprinkled on a spoonful of soft food. These extended-release capsules are appropriate for pediatric patients 2 years or older.
-Trokendi XR(R): Extended-release capsules must be swallowed whole and intact and therefore are not appropriate for children less than 6 years of age.
-Dose titration should be guided by clinical outcome.
-Co-administration with phenytoin and/or carbamazepine may require dose adjustments.

Uses:
-Initial monotherapy in patients 2 years or older with partial onset or primary generalized tonic-clonic seizures, and as adjunctive therapy for patients with partial onset or primary generalized tonic-clonic seizures or seizures associated with Lennox-Gastaut syndrome.

Usual Pediatric Dose for Migraine Prophylaxis

12 years of age and older:
IMMEDIATE RELEASE:
100 mg daily in 2 divided doses
The dose should be achieved by titration:
Week 1: No dose in the AM and 25 mg orally in the PM
Week 2: 25 mg orally in the AM and 25 mg orally in the PM
Week 3: 25 mg orally in the AM and 50 mg orally in the PM
Week 4: 50 mg orally in the AM and 50 mg orally in the PM

12 years of age and older:
EXTENDED-RELEASE:
100 mg orally once a day
The dose should be achieved by titration:
Week 1: 25 mg orally once a day
Week 2: 50 mg orally once a day
Week 3: 75 mg orally once a day
Week 4: 100 mg orally once a day

Comments:
-Dose titration rate should be guided by clinical outcome, if needed, longer intervals between dose adjustments may be used.

Use: For adults and adolescents 12 years of age and older for the prophylaxis of migraine headache

Renal Dose Adjustments

CrCl less than 70 mL/min: Reduce the usual starting and maintenance dose by 50%

Liver Dose Adjustments

Moderate to severe hepatic impairment: Use with caution

Dose Adjustments

Topiramate plasma level monitoring is not required to optimize therapy.

Dosage adjustments may be required following addition or withdrawal of phenytoin and/or carbamazepine.

Drug Discontinuation:
-Antiepileptic drugs including topiramate should not be abruptly discontinued.
-Antiepileptic drugs should be gradually withdrawn in patients both with or without a history of seizures or epilepsy so as to minimize the potential for seizures or increased seizure frequency.
-In situations where rapid withdrawal is medically required, appropriate monitoring will be necessary.

Precautions

CONTRAINDICATIONS:
Immediate-release:
-None
Extended-release:
-Qudexy XR(R): Concomitant use of metformin in patients with metabolic acidosis (as topiramate can cause metabolic acidosis, a condition for which metformin use is contraindicated)
-Trokendi XR(R): Use of alcohol within 6 hours before or after administration may significantly alter topiramate release

-Safety and effectiveness have not been established for adjunctive treatment of partial onset seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome in patients younger than 2 years.
-Safety and effectiveness have not been established for the prophylaxis of migraine headache in patients younger than 12 years.
-Trokendi XR(R): Because the capsule must be swallowed whole, this formulation is not recommended for patients younger than 6 years.

Consult WARNINGS section for additional precautions.

Dialysis

Topiramate is cleared by hemodialysis at a rate 4 to 6 times greater than a normal individual; a supplemental dose may be required
-Actual dose adjustment should take into account:
--duration of dialysis period
--clearance rate of the dialysis system being used
--effective renal clearance of topiramate in the patient being dialyzed

Other Comments

Administration advice:
-Take orally; may be taken without regard to meals
Immediate-release:
-Tablets: Should not be broken because of the bitter taste
-Capsules: May be swallowed whole or may be opened and sprinkled on a small amount (teaspoon) of soft food; mixture should be swallowed immediately and not chewed; do not store for future use
Extended-release:
-Qudexy XR(R): May be swallowed whole or may be opened and sprinkled on a small amount (teaspoon) of soft food; mixture should be swallowed immediately and not chewed; do not store for future use
-Trokendi XR(R): Must be swallowed whole and intact; alcohol should be completely avoided within 6 hours (6 hours before and 6 hours after) as data has shown the presence of alcohol alters drug release.

Missed dose:
-Immediate-release tablets/capsules: If missed, take a soon as possible unless it is within 6 hours of next dose, if within 6 hours of next scheduled dose, skip the missed dose; do not take a double dose. If more than 1 dose has been missed, the healthcare provide should be contacted.
-Extended-release: If missed, take a soon as possible, do not double the next dose. If more than 1 dose has been missed, the healthcare provide should be contacted.

General:
-Adequate hydration, especially in patients predisposed to kidney stones, is necessary to minimize the risk of kidney stone formation.
-This drug, like other antiepileptic drugs, may increase the risk of suicidal thoughts and behaviors.

Monitoring:
-Monitor for decreased sweating and increased body temperature, especially during hot weather and in pediatric patients
-Obtain ammonia level in patients developing unexplained lethargy, vomiting, or changes in mental status
-Monitor for metabolic acidosis; obtain serum bicarbonate levels when given with another carbonic anhydrase inhibitor or if metabolic acidosis is suspected
-Monitor for emergence of worsening depression, suicidal thoughts or behaviors, and/or any unusual changes in mood or behavior

Patient advice:
-Patients should be instructed to maintain adequate fluid intake to avoid the possibility of kidney stones.
-Patients should be instructed to seek immediate medical advice if they develop acute visual loss or ocular pain; any visual disturbances should be reported to their healthcare provider.
-Patients should be instructed to report decreased sweating, high or persistent fevers, hyperventilation, mental status changes, especially if accompanied by lethargy or vomiting.
-Patients should be instructed to report any unusual changes in mood or behavior, suicidal thoughts, or thoughts about self-harm.
-Patients should discuss with their healthcare provider the appropriate caution to take for driving, or engaging in any activities where loss of consciousness could result in serious danger to themselves or those around them.
-Women should be advised to speak to physician or health care professional if pregnant, intend to become pregnant, or are breastfeeding; women of childbearing potential should use effective contraception.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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