eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Theophylline: Follow-up

Author: Tracey H Reilly, MD, Attending Physician, Department of Emergency Medicine, United Health Services Hospitals
Coauthor(s): Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health; Chandra D Aubin, MD, Associate Residency Director, Division of Emergency Medicine, Assistant Professor, Washington University School of Medicine; Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
Contributor Information and Disclosures

Updated: Dec 9, 2008

Follow-up

Further Inpatient Care

  • Admit all patients with signs or symptoms of theophylline toxicity.
  • Admit patients with serial unchanged or increasing theophylline levels of more than 30 mcg/mL in acute or acute-on-chronic ingestions of sustained-release preparations.
  • Admit patients with cardiovascular or neurologic symptoms to the ICU, with airway management, monitoring, and supportive care as indicated.
  • Patients with significant cardiovascular or neurologic symptoms should receive hemodialysis. Multidose activated charcoal should be used for patients with less severe toxicity.

Further Outpatient Care

  • Patients with 2 consecutive decreasing theophylline levels of less than 30 mcg/mL, determined at least 2 hours apart, who are asymptomatic and who have no comorbid conditions may be considered for discharge.

Inpatient & Outpatient Medications

  • Inpatient medications have been discussed previously (see Medication).
  • Patients with 2 consecutive decreasing levels of less than 30 mcg/mL who are asymptomatic may be discharged, and further doses of theophylline should not be resumed until levels are within the therapeutic range (10-20 mcg/mL).
  • No outpatient medications are required for the treatment of theophylline toxicity.

Transfer

  • Patients with dysrhythmias, hemodynamic instability, or severe agitation, altered mental status, or seizures after ingestions of significant amounts of theophylline should be transferred to the ICU. These patients should also be transferred to facilities that can provide hemodialysis.

Deterrence/Prevention

  • Drug levels should be periodically monitored in patients who are being treated with theophylline.
  • Particular attention should be paid to potential drug interactions.
  • Macrolide and quinolone antibiotics should be avoided. If they are administered, theophylline levels should be carefully monitored.
  • Patients should be counseled about the potential for serious toxicity in acute and chronic overdose and about the potential for drug interactions.

Prognosis

  • The prognosis of patients with theophylline toxicity depends on the amount and severity of the ingestion. Significant ingestions increase the risk of death from dysrhythmias, refractory hypotension, or status epilepticus.
  • Hypoxic brain injury is a risk in patients with status epilepticus, prolonged hypotension, or significant aspiration causing hypoxia.

Patient Education

  • Patients should be advised of the potential for serious toxicity in acute and chronic overdose and of the potential for serious drug interactions.
  • Patients should be advised that current drugs for the treatment of asthma and chronic obstructive pulmonary disease (COPD), such as inhaled beta-agonists and inhaled steroids, offer better therapeutic effects without the risk of significant toxicity associated with theophylline.
  • For excellent patient education resources, visit eMedicine's Drug Overdose Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning, Drug Overdose, Activated Charcoal, and Poison Proofing Your Home.

Miscellaneous

Medicolegal Pitfalls

  • Because inhaled beta-agonists and steroids are effective in the treatment of asthma and chronic obstructive pulmonary disease (COPD) and because they do not have the risk of serious or fatal toxicity, a potential liability is associated with the continued prescription of theophylline for patients with these conditions.
 


More on Toxicity, Theophylline

Overview: Toxicity, Theophylline
Differential Diagnoses & Workup: Toxicity, Theophylline
Treatment & Medication: Toxicity, Theophylline
Follow-up: Toxicity, Theophylline
References
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References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].

  2. Novelli G, Rossi M, Morabito V, et al. Pediatric acute liver failure with molecular adsorbent recirculating system treatment. Transplant Proc. Jul-Aug 2008;40(6):1921-4. [Medline].

  3. Charytan D, Jansen K. Severe metabolic complications from theophylline intoxication. Nephrology (Carlton). Oct 2003;8(5):239-242. [Medline].

  4. de Pont AC. Extracorporeal treatment of intoxications. Curr Opin Crit Care. Dec 2007;13(6):668-73. [Medline].

  5. Holstege CP, Dobmeier S. Cardiovascular challenges in toxicology. Emerg Med Clin North Am. Nov 2005;23(4):1195-217. [Medline].

  6. Holstege CP, Hunter Y, Baer AB, et al. Massive caffeine overdose requiring vasopressin infusion and hemodialysis. J Toxicol Clin Toxicol. 2003;41(7):1003-7. [Medline].

  7. Lheureux P, Penaloza A, Gris M. Pyridoxine in clinical toxicology: a review. Eur J Emerg Med. Apr 2005;12(2):78-85. [Medline].

  8. Minton NA, Henry JA. Acute and chronic human toxicity of theophylline. Hum Exp Toxicol. Jun 1996;15(6):471-81. [Medline].

  9. Minton NA, Henry JA. Treatment of theophylline overdose. Am J Emerg Med. Oct 1996;14(6):606-12. [Medline].

  10. Rutten J, van den Berg B, van Gelder T, van Saase J. Severe theophylline intoxication: a delay in charcoal haemoperfusion solved by oral activated charcoal. Nephrol Dial Transplant. Dec 2005;20(12):2868-9. [Medline].

  11. Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med. Jul 1997;4(7):674-8. [Medline].

  12. Stork CM, Howland MA, Goldfrank LR. Concepts and controversies of bronchodilator overdose. Emerg Med Clin North Am. May 1994;12(2):415-36. [Medline].

  13. Watson WA, Litovitz TL, Rodgers GC, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].

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Further Reading

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Keywords

theophylline toxicity, theophylline overdose, acute theophylline overdose, chronic theophylline intoxication, methylxanthine, asthma treatment, chronic obstructive pulmonary disease treatment, COPD treatment, theophylline adverse affects, theophylline prescription, methylxanthine derivative, 1, 3-dimethylxanthine, smooth muscle relaxant, diuretic, cardiac stimulant, vasodilator, angina pectoris treatment, peripheral vascular disease treatment, bronchial asthma treatment, hypokalemia, hyperglycemia, hypercalcemia, hypophosphatemia, hypomagnesemia, and metabolic acidosis,  atrial fibrillation, atrial flutter, multifocal atrial tachycardia

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Contributor Information and Disclosures

Author

Tracey H Reilly, MD, Attending Physician, Department of Emergency Medicine, United Health Services Hospitals
Tracey H Reilly, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Chandra D Aubin, MD, Associate Residency Director, Division of Emergency Medicine, Assistant Professor, Washington University School of Medicine
Disclosure: Nothing to disclose.

Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians
Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Medical Editor

Halim Hennes, MD, MS, Pediatric Emergency Medicine Research Director, Professor, Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin
Halim Hennes, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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