The CYP3A4 induction and teratogenicity risk exists at all doses used for AUD (>200mg). For migraine prophylaxis, doses are often lower (50-100mg), but the interaction still exists. Always verify LARC regardless of indication.
Medium · 2 minNo—this is not sufficient given the Category D teratogenicity. The standard of care is to require highly effective contraception (LARC) or avoid topiramate entirely. Patient preference for weight loss does not override fetal safety.
Hard · 3 minThen topiramate could be considered, but naltrexone remains first-line for reduction goals. The IUD must be placed BEFORE starting topiramate, and pregnancy test must be negative. Document LARC verification.
Medium · 2 minReasonable alternative, but patient had prior success with naltrexone. Acamprosate has even less pregnancy data. Either could be justified with documented informed consent. The key is NOT avoiding medication entirely.
Medium · 2 minCAPTA requires notification for data tracking, not necessarily a CPS abuse report. Create a Plan of Safe Care documenting treatment engagement. Distinguish clinical monitoring from forensic testing. Focus on family preservation when mother is engaged in treatment.
Hard · 3 min