• Acute Myopia and Secondary Angle Closure Glaucoma Syndrome. A syndrome consisting of acute myopia associated with secondary angle closure glaucoma has been reported in patients receiving topiramate, with symptoms typically occurring within 1 month of therapy initiation. The primary treatment to reverse symptoms is discontinuation of Qudexy XR as rapidly as possible. If left untreated, elevated intraocular pressure can lead to serious sequelae, including permanent vision loss.
• Visual Field Defects. Visual field defects have been reported in patients receiving topiramate independent of elevated intraocular pressure. If visual problems occur at any time during topiramate treatment, consideration should be given to discontinuing the drug.
• Oligohydrosis and Hyperthermia. Oligohydrosis, resulting in hospitalization in some cases, has been reported in association with topiramate use. The majority of reports have been in pediatric patients, but all patients should be monitored closely for evidence of decreased sweating and increased body temperature, especially in hot weather. Caution should be used when Qudexy XR is prescribed with other drugs that predispose patients to heat-related disorders.
• Metabolic Acidosis. Qudexy XR can cause hyperchloremic, non-anion gap metabolic acidosis due to its inhibitory effect on carbonic anhydrase. Conditions that predispose patients to acidosis may be additive to the bicarbonate lowering effects of topiramate. Measurement of baseline and periodic serum bicarbonate during topiramate treatment is recommended. If metabolic acidosis develops and persists, consideration should be given to reducing the dose or discontinuing topiramate (using dose tapering).
• Suicidal Behavior and Ideation. Antiepileptic drugs (AEDs), including Qudexy XR increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. Patients, their caregivers, and families should be informed of these risks, and behaviors of concern should be immediately reported to healthcare providers.
• Cognitive/Neuropsychiatric Adverse Reactions. Immediate-release topiramate can cause, and therefore, Qudexy XR is expected to cause, cognitive/neuropsychiatric adverse reactions. In adults, the most frequent of these can be classified into three general categories: cognitive-related dysfunction, psychiatric/behavioral disturbances, and somnolence/fatigue. In pediatric epilepsy trials, adverse reactions included psychomotor slowing, difficulty with concentration/attention, speech disorders/related speech problems, and language problems. In migraine preventive treatment-controlled trials, the most common cognitive adverse reaction was difficulty with memory. Patients should use caution when operating machinery including automobiles. Depression and mood problems may occur.
• Fetal Toxicity. Topiramate can cause fetal harm when administered to a pregnant woman. Data from pregnancy registries indicate that infants exposed to topiramate in utero have an increased risk of major congenital malformations, including but not limited to cleft lip and/or cleft palate and of being small for gestational age. Qudexy XR should be used during pregnancy only if the potential benefit outweighs the potential risk. All women of childbearing potential should be informed of the potential hazard to the fetus and counseled to use effective contraception, keeping in mind that there is a potential for decreased contraceptive efficacy when using estrogen-containing birth control with topiramate.
• Withdrawal of Antiepileptic Drugs. Antiepileptic drugs, including Qudexy XR, should be gradually withdrawn to minimize the potential for seizures or increased seizure frequency.
• Decrease in Bone Mineral Density (BMD): Topiramate has been shown to decrease BMD and bone mineral content in pediatric patients.
• Negative effects on Growth: Topiramate may slow height increase and weight gain; carefully monitor children receiving prolonged therapy.
• Serious Skin Reactions. Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) have been reported in patients receiving topiramate. Qudexy XR should be discontinued at the first sign of a rash, unless the rash is clearly not drug related.
• Hyperammonemia and Encephalopathy. Topiramate treatment can cause hyperammonemia, with and without encephalopathy. The risk for hyperammonemia with topiramate appears dose-related. Hyperammonemia has been reported more frequently when used concomitantly with valproic acid. Patients with inborn errors of metabolism or reduced mitochondrial activity may have an increased risk of hyperammonemia. Measure ammonia if encephalopathic symptoms occur.
• Kidney Stones. Topiramate increases the risk of kidney stones. Topiramate is a carbonic anhydrase inhibitor. Carbonic anhydrase inhibitors can promote stone formation by reducing urinary citrate excretion and by increasing urinary pH. The concomitant use of Qudexy XR with any other drug producing metabolic acidosis, or potentially in patients on a ketogenic diet, may create a physiological environment that increases the risk of kidney stone formation, and should therefore be avoided. Increased fluid intake increases the urinary output, lowering the concentration of substances involved in stone formation. Hydration is recommended to reduce new stone formation.
• Hypothermia with Concomitant Valproic Acid Use. Hypothermia has been reported in association with topiramate use with concomitant valproic acid, both in the presence and in the absence of hyperammonemia. Consideration should be given to stopping topiramate or valproate in patients who develop hypothermia.

• Lactation: Topiramate is excreted in human milk. The effects of topiramate on milk production are unknown. Diarrhea and somnolence have been reported in breastfed infants whose mothers receive topiramate treatment. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Qudexy XR and any potential adverse effects on the breastfed infant from Qudexy XR or from the underlying maternal condition.
• Females of Reproductive Potential: Women of childbearing potential who are not planning a pregnancy should use effective contraception because of the risks to the fetus of major congenital malformations, including but not limited to oral clefts and of being small for gestational age.
• Pediatric Use: The adverse reactions (both common and serious) in pediatric patients are similar to those seen in adults. Qudexy XR is not indicated for any use in patients less than 2 years of age.
• Pregnancy: Increased risk of major congenital malformations, including but not limited to cleft lip and/or palate and for being small for gestational age.
• Patients with Renal Impairment: One-half of the usual adult dose is recommended.
• Patients Undergoing Hemodialysis: To avoid rapid drops in topiramate plasma concentration, a supplemental dose of topiramate may be required.
• Geriatric use: Dosage adjustment may be necessary for elderly with impaired renal function.

• Antiepileptic Drugs: Concomitant administration of phenytoin or carbamazepine with topiramate resulted in a clinically significant decrease in plasma concentrations of topiramate. A dosage adjustment may be needed. Concomitant administration of valproic acid and topiramate has been associated with hypothermia and hyperammonemia with or without encephalopathy.
• Other Carbonic Anhydrase Inhibitors: Patients should be monitored for the appearance or worsening of metabolic acidosis when Qudexy XR is given concomitantly with another carbonic anhydrase inhibitor.
• CNS Depressants: Qudexy XR should be used with extreme caution if used in combination with alcohol and other CNS depressants.
• Oral Contraceptives: The possibility of decreased contraceptive efficacy and increased breakthrough bleeding may occur.
• Hydrochlorothiazide (HCTZ): The addition of HCTZ to Qudexy XR may require a decrease in the Qudexy XR dose.
• Pioglitazone: When Qudexy XR is added to pioglitazone therapy or pioglitazone is added to Qudexy XR therapy, careful attention should be given to the routine monitoring of patients for adequate control of their diabetic disease state.
• Lithium: Lithium levels should be monitored when co-administered with high-dose Qudexy XR.
• mitriptyline: Some patients may experience a large increase in amitriptyline concentration in the presence of Qudexy XR and any adjustments in amitriptyline dose should be made according to the patient’s clinical response and not on the basis of plasma levels.

• Epilepsy: The most common adverse reactions in adult and pediatric controlled, clinical trials of immediate-release topiramate were: paresthesia, anorexia, weight loss, speech disorders and related speech problems, fatigue, dizziness, somnolence, nervousness, psychomotor slowing, abnormal vision, and fever.
• Migraine: The most common adverse reactions at recommended doses in adult and adolescent controlled, clinical trials were: paresthesia, anorexia, weight loss, difficulty with memory, taste perversion, diarrhea, hypoesthesia, nausea, abdominal pain, and upper respiratory tract infection.
• Qudexy XR has been studied in a randomized, placebo-controlled, phase 3 clinical study in 249 adult patients with a history of partial-onset seizures with or without secondary generalization. See the ADVERSE REACTIONS section of the Qudexy XR full prescribing information for adverse reaction rates from this clinical trial.
• The most serious adverse reactions are listed above in the WARNINGS AND PRECAUTIONS section.

This safety information is not comprehensive.  Please refer to the full Prescribing Information for Qudexy XR and Medication Guide. You can also visit www.upsher-smith.com or call 1-888-650-3789.

You are encouraged to report suspected adverse reactions to Upsher-Smith Laboratories, LLC at 1-855-899-9180 or to the FDA by visiting www.fda.gov/medwatch.

Qudexy XR (topiramate) Extended-Release Capsules are indicated for:

• Migraine: Preventive treatment of migraine in patients 12 years and older.
• Epilepsy: Initial monotherapy for the treatment of partial-onset or primary generalized tonic-clonic seizures in patients 2 years and older. Adjunctive therapy for the treatment of partial-onset seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut Syndrome in patients 2 years and older.

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