Topiramate Shows Potential for Treatment of Alcohol Dependence
Results of several small clinical trials suggest that topiramate, an anticonvulsant that acts on specific GABA and glutamate neuropathways, improves outcomes in persons with alcohol dependence compared with placebo; however, few studies have compared topiramate to other medications for alcohol dependence. In a 12-week controlled trial, Brazilian investigators randomized 155 alcohol-dependent adults to receive topiramate (induction to 300 mg per day), naltrexone (50 mg per day), or placebo after a 1-week detoxification period.
- In intent-to-treat analyses, event rates for topiramate, naltrexone, and placebo, respectively, were
- 7.8*, 5.7, and 5.0 weeks for time to first relapse.
- 8.2*, 6.6, and 5.6 weeks for cumulative abstinence duration.
- 3.4*, 5.0, and 5.9 weeks for mean weeks of heavy drinking.
- The percentage of patients remaining continuously abstinent were
- 67%*, 53%, and 43% at 4 weeks.
- 62%*, 41%, and 32% at 8 weeks.
- 46%, 29%, and 28% at 12 weeks.
- Side-effects did not differ between the groups.
*p<0.05 compared with placebo.
In the same way SSRIs paved the way for primary care physicians to treat depression, safe and effective medications for alcohol use disorders will be essential to bringing their treatment into the mainstream of medical practice. Evidence for the efficacy of the currently FDA-approved medications (disulfiram, naltrexone, and acamprosate) has been mixed, and the inability to make a definitive case for them is a major factor in their limited adoption by physicians. These results suggest that topiramate is superior to placebo and might be superior to naltrexone in improving outcomes among patients with alcohol dependence. Larger comparative trials are warranted.Peter D. Friedmann, MD, MPH