Theophylline Toxicity in Emergency Medicine Clinical Presentation

Author: Greg Hymel, MD; Chief Editor: Asim Tarabar, MD more...

Updated: Jul 12, 2011

What would you like to print?

History
Physical
Causes
Show All

History

Symptomology correlates better with single acute ingestions than with chronic overexposures. Symptoms of acute theophylline overdose are as follows:

Nausea
Vomiting - Severe and protracted, acute overdose, chronic overdose, sustained-release preparations, immediate-release preparation
Abdominal pain
Mild metabolic acidosis
Hypokalemia
Hypophosphatemia
Hypomagnesemia
Hypocalcemia/hypercalcemia
Hyperglycemia
Tachycardia

Chronic theophylline overdose has minimal GI signs or symptoms.

Seizures, hypotension, and significant dysrhythmias usually are observed when serum levels approach 80 mcg/mL.

Seizures are more common with acute overdose than with chronic overdose. In chronic exposures, seizures may develop at lower serum concentrations (40-60 mcg/mL).

Cardiac dysrhythmias are more common following a chronic overdose rather than acute overdose and with lower serum concentrations.

Cardiovascular

Sinus tachycardia (most common)
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Multifocal atrial tachycardia
Ventricular tachycardia
Hypotension (severe overdoses) - Due to β₂ effect/agonsim
Ventricular fibrillation
Pulseless electrical activity (PEA)
Cardiac arrest

Pulmonary

Increased respiratory rate leads to respiratory alkalosis
Acute lung injury (ALI)
Respiratory failure leads to arrest

Neurological

Tremors (most common)
Restlessness
Agitation
Hallucinations
Headaches
Irritability
Seizures (Persistent seizures may occur with serum levels >25 mcg/mL.)

Gastrointestinal

Nausea
Vomiting
Abdominal cramps
Diarrhea

Chronic theophylline toxicity

Drug interactions (eg, ethanol [ETOH], cimetidine, oral contraceptives, allopurinol, macrolide, quinolone antibiotics)
Liver disease
Congestive heart failure
Febrile viral upper respiratory illness

Acute theophylline toxicity

Nonintentional overdose
Intentional overdose

Proceed to Differential Diagnoses

Contributor Information and Disclosures

Author

Greg Hymel, MD Assistant Medical Director, Department of Emergency Medicine, Mercy Saint Vincent Medical Center

Greg Hymel, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-11178. [Full Text].
Seneff M, Scott J, Friedman B, Smith M. Acute theophylline toxicity and the use of esmolol to reverse cardiovascular instability. Ann Emerg Med. Jun 1990;19(6):671-3. [Medline].
Kearney TE, Manoguerra AS, Curtis GP, Ziegler MG. Theophylline toxicity and the beta-adrenergic system. Ann Intern Med. Jun 1985;102(6):766-9. [Medline].
Brashear RE, Aronoff GR, Brier RA. Activated charcoal in theophylline intoxication. J Lab Clin Med. Sep 1985;106(3):242-5. [Medline].
Charytan D, Jansen K. Severe metabolic complications from theophylline intoxication. Nephrology (Carlton). Oct 2003;8(5):239-42. [Medline].
Cooling DS. Theophylline toxicity. J Emerg Med. Jul-Aug 1993;11(4):415-25. [Medline].
Gaudreault P, Harwood-Nuss. Methylxanthines, Toxicology. In: Clinical Practice of Emergency Medicine. 4^th ed. 2005:1649-1652.
Henderson A, Wright DM, Pond SM. Management of theophylline overdose patients in the intensive care unit. Anaesth Intensive Care. Feb 1992;20(1):56-62. [Medline].
Kallstrom TJ. Evidence-based asthma management. Respir Care. Jul 2004;49(7):783-92. [Medline].
Marshall H, Emerman CL, Tintinalli J. Theophylline, Toxicology and Pharmacology. In: Emergency Medicine, A Comprehensive Study Guide. 6^th ed. 2004:1098-1101.
Medical Economics Staff. Drugs. In: Physician's Desk Reference. Medical Economics Co; 1997.
Micromedex. Theophylline. In: Micromedex. 1974-2008:36.

View Table List

Read more about Theophylline Toxicity in Emergency Medicine on Medscape