In this case scenario, I outline a situation of topiramate-induced cognitive impairment. Topiramate is an anticonvulsant medication that may be used for headache prophylaxis and is known to cause cognitive slowing, manifesting as difficulties in concentration, memory, and speech.
JD is a 55-year-old male who presents to the clinic for a routine follow-up. He has a history of traumatic brain injury 4 years ago which has led to cognitive problems. He reports having experienced occasional dizziness and worsening confusion over the past month. His caregiver mentions that his memory lapses have become more frequent. His speech and word finding have worsened as well.
His current medications include:
- Atorvastatin 10 mg daily
- Donepezil 10 mg daily
- Aspirin 81 mg daily
- Lisinopril 20 mg daily
- Topiramate 100 mg BID
- Hydralazine 5 mg three times daily
- Metformin 1000 mg twice daily
- Sitagliptin 25 mg daily
- Glipizide 10 mg BID
- Omeprazole 20 mg daily
- Tums as needed
- Mobic 15 mg daily
- Acetaminophen 650 mg as needed
- Meclizine 25 mg as needed
- Senna-S 1 tab twice daily
- Miralax 17 grams daily
- Diphenhydramine 50 mg at bedtime for sleep
This certainly could be a case of topiramate-induced cognitive impairment. The dose of topiramate is substantial and it has to considered as a potential cause of the worsening symptoms. Ideally, we should reduce the topiramate to help assess if this is contributing to the worsening cognitive impairment and dizziness. Cognitive impairment due to topiramate is a dose-dependent adverse effect (i.e. higher the dose, the more likely it is to occur).
Anticholinergic medications are not ideal in this situation either. Diphenhydramine reduction and discontinuation should be considered in addition to changes to the topiramate. Anticholinergic activity can directly oppose any potential benefits of donepezil. In addition to the negative cognitive impacts of diphenhydramine, it also may be contributing to constipation. This patient is requiring two scheduled constipation medications in Senna-S and Miralax.
The dizziness could be blood pressure related so it would be appropriate to review those vital signs. The hydralazine use at that low of a dose is very annoying to me anyway and I’d be looking for a reason to try to get rid of that medication to reduce pill burden. Dizziness and cognitive changes could be associated with hypoglycemia symptoms. During periods of confusion or dizziness, it may be appropriate to ensure that blood sugars are not low. Glipizide would be the most likely agent to cause hypoglycemia (if present).
What else would you review in this possible case scenario of topiramate-induced cognitive impairment?
- 30 medication mistakes PDF
- 18+ Page Drug Interaction PDF
- 10 Commandments of Polypharmacy Webinar based on my experiences in clinical practice
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Nice review Eric. I think your review is complete.
A while back, I was told an easy way to remember the cognitive impairment with topiramate is by a nickname ‘ dopamax’, cause it make you dopey.