SAN FRANCISCO (FRONTLINE MEDICAL NEWS) When naltrexone is not an option for alcohol use disorder, topiramate is a good choice for many patients, according to Dr. Steven L. Batki, psychiatry professor and addiction researcher at the University of California, San Francisco.

Naltrexone is often the first-line option, because it’s relatively inexpensive, simple to dose orally or by injection, and “probably has the greatest evidence” for reducing use and craving, he said at the American Psychiatric Association’s Institute on Psychiatric Services ( JAMA 2014;311:1889-1900 ). But GI upset is common with the drug, and, like disulfiram, it can cause liver problems. It’s also contraindicated with recent opioid use.

When those are problems, “I would go to topiramate. It reliably reduces craving … might reduce postwithdrawal dysphoria and anxiety,” and numb the reaction to drinking cues. “There’s quite an effect size for abstinence [versus] placebo.” In some studies, it “works even better than acamprosate or naltrexone,” Dr. Batki said.

The issue with topiramate (Topamax), however, is dose titration. If it’s too fast, the reason for the drug’s slang name – “dopamax” – becomes clear: “excessively rapid up-titration in some patients has led to word searching, and other memory and concentration problems. You can also get paresthesias,” he said.

Because of that, in a study Dr. Batki led that found topiramate reduces alcohol use and hyperarousal in veterans with posttraumatic stress disorder, “we increased the dose very slowly,” starting at 25 mg a day and going up over 6 weeks to 300 mg a day; 300 mg daily is the standard dose, but “I think much lower doses might be effective.” Several studies show as little as 200 mg and perhaps even less may be effective for alcohol use. “We really don’t know what the effective dose is,” he said ( Alcohol Clin. Exp. Res. 2014;38:2169-77 ).

Kidney stones, metabolic acidosis, and narrow angle glaucoma are all possible side effects of the drug, “so anyone who gets eye pain on topiramate” must be taken off immediately. As with other renally excreted alcohol treatment drugs, “cut the dose in half if patients are renally impaired,” Dr. Batki said.

Dosing with another treatment option, gabapentin is generally 600 mg t.i.d., but its effective dose is also “not fully worked out yet.” It seems to increase abstinence and decrease craving but at the cost for some of sedation, dizziness, and edema. “It’s important to check for lower extremity edema. I’ve seen quite a bit of that, especially in women,” he said.

Meanwhile, “there hasn’t been an American study with intention-to-treat analysis where acamprosate has separated from placebo; on secondary analysis it did work. It probably does work.” Dosing is about 2 grams a day, however. “I just haven’t found very many patients who can remember to take two big pills three times a day,” he said.

Dr. Batki has no relevant disclosures.