Precautions and Warnings With Topiramate

Prior to starting any new medication, it is important to be aware of all the drug's precautions and warnings. With topiramate, these warnings include watching out for certain drug interactions, knowing the risks of using the medication during pregnancy, and letting your healthcare provider know if you have liver or kidney disease. Possible side effects of topiramate include decreased sweating, glaucoma, metabolic acidosis, and cognitive or psychiatric problems.

Topiramate: What Should I Tell My Healthcare Provider?

You should talk with your healthcare provider prior to taking topiramate (Topamax®) if you have:
  • Kidney disease, such as kidney failure (renal failure)
  • Liver disease, such as liver failure or cirrhosis
  • Kidney stones
  • Glaucoma
  • Severe respiratory conditions
  • Severe diarrhea
  • Any allergies, including allergies to food, dyes, or preservatives.
Also, let your healthcare provider know if you are:
  • Pregnant or thinking of becoming pregnant
  • Breastfeeding
  • Following a ketogenic diet.
Make sure to tell your healthcare provider about all other medicines you may be taking, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Some Topiramate Precautions and Warnings

Some warnings and precautions to be aware of with topiramate include:
  • Topiramate can cause a specific type of electrolyte imbalance called metabolic acidosis. This is fairly common with topiramate and can become a problem if it lasts too long or is severe. Signs of metabolic acidosis include rapid breathing, fatigue, loss of appetite, and an irregular heart rhythm (arrhythmia). Metabolic acidosis can increase your risk of kidney stones, rickets, and osteoporosis. Chronic metabolic acidosis in children can stunt their growth.
Certain people have a higher risk of developing metabolic acidosis, such as those with kidney disease, diarrhea, surgery, severe respiratory conditions, or people following a ketogenic diet (see Epilepsy Diet). It is recommended that your healthcare provider check your bicarbonate level (which is a measure of metabolic acidosis) before starting topiramate and regularly thereafter, to make sure you are not developing this condition.
  • Topiramate can cause glaucoma, a serious condition of the eye. Tell your healthcare provider immediately if you have sudden vision problems, especially if accompanied by eye pain.
  • Topiramate can affect the body's ability to cool itself by sweating. Decreased sweating, especially in warm weather or accompanied by a fever, can be dangerous. Tell your healthcare provider if you notice decreased sweating.
  • As with all epilepsy medications, topiramate should be stopped gradually to reduce the risk of increased seizures.
  • Topiramate can cause cognitive problems, such as confusion, problems with concentration or attention, memory loss, and speech problems (such as difficulty finding the right words).
  • Topiramate can cause psychiatric problems, such as depression, anxiety, hallucinations, paranoia, and suicidal actions or thoughts.
  • Topiramate can cause drowsiness and fatigue. Be sure you know exactly how topiramate affects you before you drive or operate heavy machinery.
  • Very rarely, sudden unexplained death has occurred in people taking topiramate for epilepsy. However, this does not seem to be significantly more common than in people who were not taking topiramate.
  • Combining topiramate with valproic acid (Depakene®) or divalproex sodium (Depakote®, Depakote ER®) may increase your risk of increased ammonia levels in your blood, which can cause brain problems. It is not known if topiramate alone can cause this problem. Be sure to tell your healthcare provider if you experience signs of this problem, such as unexplained lethargy, vomiting, and mental problems (such as confusion).
  • Topiramate can cause kidney stones. This risk is increased for people taking carbonic anhydrase inhibitors (see Drug Interactions With Topiramate) or people following a ketogenic diet. It is important to drink plenty of fluids to help prevent kidney stones.
  • One of the most common topiramate side effects is paresthesia (unusual sensations, such as burning, tingling, or pricking).
  • Since topiramate is cleared from the body through the kidneys, people with kidney disease require lower topiramate doses.
  • Since the liver also helps to clear topiramate from the body, topiramate should be used cautiously in people with liver disease.
  • Topiramate can interact with other medications (see Drug Interactions With Topiramate).
  • Topiramate is a considered a pregnancy Category D medication. This means that topiramate may cause harm to an unborn baby if it is used during pregnancy. In particular, there is evidence that topiramate taken during early pregnancy may cause cleft lip and/or cleft palate (oral clefts) in babies.

In general, topiramate is not recommended for use during pregnancy, unless the benefits to the pregnant woman clearly outweigh any possible risks to the unborn child. Talk to your healthcare provider about the risks and benefits of using topiramate during pregnancy (see Topamax and Pregnancy for more information).

  • Topiramate passes through breast milk. Therefore, if you are breastfeeding or plan to start breastfeeding, be sure to talk with your healthcare provider about using topiramate (see Topamax and Breastfeeding for more information).


  • Early evidence suggests that seizure medications, including topiramate, may increase the risk of suicidal thoughts or behaviors (see Seizure Medications and Suicide for more information).
Know the Signs - Concussion Safety

Topiramate (Topamax)

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