Topiramate Treatment of Alcohol Use Disorders in Veterans With Post Traumatic Stress Disorder (PTSD): A Pilot Controlled Trial of Augmentation Therapy
Condition: PTSD; Alcohol Abuse; Alcoholism
MeSH terms: Alcoholism; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
Study type: Interventional
Phase: Phase 4

Summary: 
      The proposed project aims to:

        1. Obtain a preliminary assessment of the efficacy of topiramate treatment in reducing
           alcohol use in veterans with Post Traumatic Stress Disorder (PTSD) and alcohol
           dependence;

        2. Obtain preliminary assessments of safety/tolerability of topiramate in these patients;

        3. Assess the feasibility of recruitment and retention for topiramate treatment in this
           comorbid population; and 4) to inform the design of a planned subsequent larger
           controlled trial of topiramate.

      PRIMARY HYPOTHESIS: Topiramate treatment combined with Medical Management alcohol counseling
      will be associated with a significant decrease in percent drinking days from baseline to end
      of treatment.

      SECONDARY HYPOTHESIS: There will be significantly less percent drinking days in the
      topiramate treatment group compared to the placebo group.
    

Detailed description: 
      The goal of the proposed project is to improve the treatment of veterans with co-occurring
      Post Traumatic Stress Disorder (PTSD) and alcohol dependence. Exposure to the stresses of
      combat is known to be associated with risk for both PTSD and alcohol and other substance use.
      PTSD and alcohol use disorders occur frequently among returning OEF/OIF veterans. Alcohol and
      substance use are risk factors for the development of PTSD, moderators of PTSD symptom
      severity, and potential consequences of PTSD. Alcohol is by far the most common substance of
      abuse in patients with PTSD, and its use may represent an attempt by PTSD patients to
      "self-medicate" symptoms such as hyperarousal. However, to date there has been little
      research to develop pharmacotherapies that would, ideally, reduce both alcohol use and PTSD
      symptoms.

      Topiramate is one of the few medications for alcohol dependence that has also been tested as
      a potential medication to treat PTSD. Topiramate's efficacy in alcohol dependence has been
      shown in two recent large controlled trials. Several open trials have suggested that
      topiramate may be effective in reducing PTSD symptoms while the results of two small
      controlled trials have been mixed.

      A clinical trial of topiramate is therefore indicated in order to achieve the following
      specific aims:

      The primary aim is to obtain a preliminary assessment of the efficacy of topiramate in
      increasing the percent of days abstinent from alcohol use from baseline to the end of
      treatment in veterans with PTSD and alcohol abuse/dependence who are drinking heavily.

      The secondary aim is to obtain a preliminary assessment of the efficacy of topiramate in
      increasing the percent of days abstinent from alcohol as compared to placebo.

      Additional aims include the following:

        -  To obtain a preliminary assessment of the efficacy of topiramate in reducing other
           measures of alcohol use such as percent heavy drinking days, number of drinks per week,
           number of drinks per drinking day, and alcohol craving.

        -  To obtain a preliminary assessment of the efficacy of topiramate in reducing PTSD
           symptom severity in veterans with chronic PTSD and alcohol abuse/dependence.

        -  Informing the design of a planned subsequent larger controlled trial of topiramate in
           veterans with chronic PTSD and alcohol abuse/dependence

        -  To obtain an estimate of topiramate vs. placebo effect size for future studies. B. To
           obtain a preliminary assessment of the effects of topiramate treatment on measures of
           risk-taking behavior in veterans with chronic PTSD and alcohol abuse/dependence.

      To achieve these aims, we will conduct a prospective, parallel groups, randomized,
      double-blind, placebo-controlled flexible-dose pilot clinical trial of topiramate in veterans
      with PTSD and alcohol abuse/dependence who are already receiving standard treatment for PTSD
      but still drink heavily. The primary treatment outcome will be percent days abstinent from
      alcohol; secondary outcomes will include other alcohol use measures, PTSD symptom severity,
      adverse effects, recruitment and retention rates.
    

Intervention name(s): Topiramate; Placebo administration
Intervention type(s): Drug; Other
Intervention description(s): After random assignment, topiramate will be titrated up over 5 weeks. Dosing begins at 25 mg per day, and increase in the second week to 25 mg twice per day; in the third week to 50 mg twice/day; in the fourth week to 75 mg twice/day; in the 5th week to 100 mg twice/day; and in weeks 6-11 increased to and maintained at 100 mg in the morning and 200 mg at night. Patients will receive the highest dose tolerated, not to exceed 300 mg per day. Adjustments are permitted throughout titration. Once maximum tolerated dosage is reached, subjects will be asked to maintain dosage for remainder of the treatment phase. Upon completing the 6 week maintenance period subjects will taper off over a 7-day period (Week 12). If subjects experience significant side effects, the dosage may be adjusted.; Placebo pills will be prepared by the UCSF pharmacy which will be indistinguishable from the topiramate pills used in that arm. Both topiramate and placebo will then be delivered to the VA pharmacy. A consulting biostatistician will randomly assign participants to either the topiramate or placebo group. The dosing of placebo pills will follow the same regimen as outlined for the topiramate arm. In the event of a safety issue, there will be a procedure for unblinding only that participant.
Other intervention name(s): Topamax; Qnexa; Placebo; Sugar pill
Intervention MeSH terms: Topiramate
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: PTSD; Alcohol abuse; Alcoholism; Topiramate; Stress Disorder, Post Traumatic; Chronic Post-Traumatic Stress Disorder