Theophylline Toxicity

Updated: Aug 31, 2020
  • Author: Christopher P Holstege, MD; Chief Editor: Stephen L Thornton, MD  more...
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Practice Essentials

Theophylline (1,3-dimethylxanthine) can indirectly stimulate both β1 and β2 receptors through release of endogenous catecholamines. It is used for the treatment of pulmonary conditions, including asthma and chronic obstructive pulmonary disease (COPD). In neonates, theophylline can be used for the treatment of apnea. However, medication, diet, and underlying diseases can alter its narrow therapeutic window. Drug interactions, adverse effects, and limited efficacy curb its use when other agents are available.

The 2016 Global Intitiative for Chronic Obstructive Lung Disease (GOLD) guidelines for management of COPD recommended theophylline only if other bronchodilators were unavailable or unaffordable, but in the 2018 guidelines, no situations are suggested for theophylline use. [1]  In addition, evidence regarding the effect of low-dose theophylline on exacerbation rates is not clear and a meta-analysis suggested that theophylline slightly increases all-cause death in COPD patients. [2]  This has all led to significantly diminished use of theophylline for the treatment of asthma and, consequently, decreased reports of theophylline toxicity. [3]

Acute theophylline overdose presents as follows:

  • Nausea and vomiting
  • Abdominal pain
  • Tachycardia
  • Hypotension
  • Metabolic acidosis
  • Hypokalemia
  • Hypercalcemia
  • Hypophosphatemia
  • Hypomagnesemia
  • Hyperglycemia
  • Leukocytosis

Chronic intoxication often causes milder gastrointestinal symptoms and does not cause electrolyte shifts or hypotension, as is observed in acute overdose. However, significant dysrhythmias and seizures are common with lower levels of the drug in chronic intoxication and in acute-on-chronic overdose. See Presentation and Workup.

Treatment consists of decontamination and supportive care. Hemodialysis should be considered if the theophylline level is more than 100 mcg/mL in acute ingestions and more than 60 mcg/mL in chronic, as well as in patients who develop seizures, refractory hypotension that is unresponsive to fluids, or unstable dysrhythmias, regardless of the theophylline level. See Treatment.

For patient education information, see First Aid for Poisoning in Children and Child Safety Proofing.




The primary mechanisms of theophylline therapeutic efficacy and its toxicity are through the excess of catecholamines and adenosine antagonism. Adenosine blockade can theoretically reduce histamine release and indirectly reverse bronchospasm. In addition, theophylline inhibits phosphodiesterase, resulting in elevation of cyclic adenosine monophosphate (cAMP) and consequent beta-adrenergic enhancement.

Theophylline is absorbed rapidly and completely after oral administration. Peak serum levels for immediate release preparations are relatively rapid and can range from 30-120 minutes. Fasting or large volumes of fluid enhance absorption. Enteric-coated and sustained-release tablets have a delayed absorption with peak between 6 and 10 hours. It is important to recognize that these time intervals are much longer in the setting of overdose. The intravenous form of theophylline (aminophylline) reaches peak serum levels within 30 minutes. [4]

Theophylline is ~60% protein bound and has a volume of distribution of 0.5 L/kg. Therapeutic serum levels range from 10-20 mcg/mL. Toxic levels are considered to be higher than 20 mcg/mL; however, adverse effects may be evident within the normal therapeutic range. Severe complications including cardiac dysrhythmias, seizures, and death can be observed with levels of 80-100 mcg/mL. With long-term exposure, those levels causing such adverse clinical outcomes are lower (40-60 mcg/mL).

Theophylline is eliminated by the hepatic cytochrome P450 system (85-90%) and by urinary excretion (10-15%). The half-life is 4-8 hours in young adults and is shorter in children and smokers. Diet, cardiac or liver disease, tobacco use, and medications (eg, cimetidine, erythromycin, oral contraceptives) affecting the cytochrome P450 system (CYP1A2) can alter the half-life.

Theophylline affects the cardiovascular (CV), central nervous (CN), gastrointestinal (GI), pulmonary, musculoskeletal, and metabolic systems. Hypokalemia, hyperglycemia, hypercalcemia, hypophosphatemia, and metabolic acidosis commonly occur after an acute overdose.



Causes of chronic theophylline toxicity include the following:

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

Congestive heart failure with hepatic congestion has been demonstrated to reduce the clearance of theophylline by 50% while doubling the half life, thereby reducing drug elimination, increasing concentrations, and leading to toxic effects.  Other factors known to reduce theophylline clearance include increased age and liver enzyme–inhibiting medications. [5]  

Acute theophylline toxicity is caused by intentional or accidental overdose. 



The 2018 annual report of the American Association of Poison Control Centers' National Poison Data System documented 88 single exposures to aminophylline or theophylline, with 3 in children younger than 6 years, 3 in those 6 to 12 years, 34 in adolescents ages 13-19 years and 75 in persons 20 years or older. Of the 46 exposures treated in health care facilities, 8 were reported to have major adverse outcomes with one death. [3]  Documented toxic exposures have decreased markedly over the past decade as the use of theophylline for the management of asthma and COPD has diminished. [6]