Theophylline Toxicity 

Updated: Nov 01, 2019
Author: Greg Hymel, MD; Chief Editor: Asim Tarabar, MD 

Overview

Practice Essentials

Theophylline (1,3-dimethylxanthins) 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]

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

 

Pathophysiology

Major 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, high levels of theophylline inhibit phosphodiesterase, resulting in elevation of cyclic adenosine monophosphate (cAMP) and consequent adrenergic stimulation.

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 in 30 minutes.[4]

Theophylline is around 60% protein bound and has a distribution volume 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 the levels of 80-100 mcg/mL. In chronic exposure, those levels could be lower (40-60 mcg/mL).

Theophylline is eliminated by the hepatic cytochrome P-450 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 (cimetidine, erythromycin, oral contraceptives) affecting the cytochrome P-450 system (CYP1A2) can affect the half-life.

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

Etiology

Causes of chronic theophylline toxicity include drug interactions (eg, ethanol [ETOH], cimetidine, oral contraceptives, allopurinol, macrolide, quinolone antibiotics), liver disease, congestive heart failure and 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 and increasing concentrations leading to toxic effects.  Other recognised factors which can reduce theophylline clearance include increased age and liver enzyme inhibiting medications.[5]  

Acute theophylline toxicity is caused by intentional or accidental overdose. 

Epidemiology

The 2017 annual report of the American Association of Poison Control Centers' National Poison Data System documented 73 single exposures to theophylline, with 7 in children younger than 6 years, 4 in adolescents ages 13-19 years and 62 in persons 20 years or older.[3] Of the 37 theophylline exposures treated in health care facilities, 3 were reported to have major adverse outcomes but no deaths were noted. Documented toxic exposures have decreased markedly over the past decade as the use of theophylline for the management of asthma has diminished.[6]

 

Presentation

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.

Physical

Cardiovascular findings include:

  • 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 findings include increased respiratory rate leading to respiratory alkalosis, acute lung injury (ALI) and respiratory failure. Neurological signs include tremors (most common), restlessness and agitation, hallucinations, headaches and irritability. Persistent seizures may occur with serum levels >25 mcg/mL. Gastrointestinal manifestions are nausea, vomiting, abdominal cramps and diarrhea.

 

DDx

 

Workup

Laboratory Studies

Obtain serum theophylline level upon presentation and then every 2 hours until the level falls. This is especially important following ingestion of extended-release formulations. Theophylline can form bezoars, resulting in ongoing absorption and toxicity despite general measures at GI decontamination.

WBC can be elevated (due to increased catecholamine activity).

Obtain acetaminophen (paracetamol) level.

Obtain aspirin (ASA) level, particularly in patients with history and findings suggestive of aspirin toxicity, including but not limited to metabolic acidosis, respiratory alkalosis, and change of mental status.

Order electrolytes and glucose tests to evaluate for the following:

  • Hypokalemia (serial testing of serum potassium levels may be required)

  • Hyperglycemia

  • Metabolic acidosis (lactate)

  • Hypocalcemia/hypercalcemia

  • Hypophosphatemia

  • Ketosis

Test for pregnancy in women of childbearing age.

Imaging Studies

A CT scan of the brain is indicated if seizures occur.

Other Tests

Electrocardiogram is performed to look for evidence of electrolyte abnormalities and dysrhythmias. Also, ECG should be used to evaluate for the signs of TCAs or other cardioactive drug toxicity.

Lumbar puncture may be required for the evaluation of new-onset seizures.

 

Treatment

Emergency Department Care

Evaluate ABCs (airway, breathing, circulation) and intervene as necessary. Endotracheal intubation may be needed in patients who require high-dose benzodiazepines or barbiturates to control seizures. Vascular access for hemoperfusion may be required.

Consider gastric lavage (unless contraindicated) if the patient has recently (< 1 h) ingested a significant amount or a sustained-release preparation of theophylline or if theophylline bezoar formation is suspected. Gastric lavage should be considered in intubated patients. Endoscopic bezoar fragmentation and retrieval may be utilized if lavage is not efficacious.

Administer activated charcoal. Multidose activated charcoal (MDAC) enhances elimination of theophylline. It is a very effective method of elimination, and it is considered the mainstay treatment of theophylline toxicity. It is important to aggressively control nausea and vomiting in order to perform MDAC treatment. It is also important that the patient is able to protect his or her airway in order to prevent aspiration of activated charcoal, which can be detrimental. Administer the cathartic, sorbitol, with the activated charcoal one time.

Perform whole-bowel irrigation (WBI) in patients with exposure to sustained-release theophylline preparations.

Administer polyethylene glycol electrolyte solution.

  • Adults: 2 liters per hour until clear rectal effluent
  • Children: 500 mL/h until clear rectal effluent

Theophylline-induced seizures tend to be resistant to treatment. Benzodiazepines (eg, lorazepam) are considered the first line of treatment. Historically, phenobarbital prophylaxis was used in patients at high risk for seizures. High-risk cases include the following:

  • Acute overdose with theophylline levels higher than 80 mcg/mL
  • Chronic toxicity with levels higher than 40 mcg/mL
  • Patients older than 60 years or younger than 3 years

Benzodiazepines (IV) and phenobarbital may be used to treat seizures but barbiturates can precipitate hypotension. Phenobarbital has the added advantage of enhancing the hepatic metabolism of theophylline.

Hypotension resistant to isotonic fluids (10-20 mL/kg) may require vasopressors with predominantly alpha-agonistic activity (eg, phenylephrine, norepinephrine). In patients with theophylline toxicity, beta-blockade with propranolol has been shown to successfully reverse peripheral beta receptor-mediated hypotension without apparent effect on concomitant tachycardia. However, always consider the risk of beta-adrenergic blockade to patients with preexistent bronchospastic disease.

Esmolol, a short-acting beta-blocker, has been used successfully for unstable supraventricular tachycardia and related hypotension in theophylline overdose.[7] Exercise caution with beta-blocking agents because of their negative inotropic effects. Esmolol is a relatively selective beta1-receptor antagonist; thus, it may not have as much effect on beta2-mediated hypotension as less-selective agents (eg, propranolol), although it is less likely to induce bronchospasm than other beta-blockers.

Consider hemoperfusion with the following:

  • Symptomatic patients with levels exceeding 90 mcg/mL in acute ingestions
  • Theophylline concentrations exceeding 40 mcg/mL (chronic ingestion)
  • Presence of life-threatening toxicity
  • Persistent seizures
  • Hypotension that is not responding to IV fluids
  • Ventricular dysrhythmia

Hemodialysis is an alternative method of elimination enhancement but is considerably less effective than hemoperfusion.

Correct electrolyte abnormalities in patients with ECG changes (eg, QTc prolongation) and/or ventricular dysrhythmias. Current recommendations for treating patients with tachycardia, hypotension, anxiety, and vomiting from theophylline overdose may include the following:

  • Fluid bolus with isotonic fluid (20 mL/kg)
  • Metoclopramide or ondansetron to help control vomiting
  • Propranolol to increase blood pressure - Reportedly propranolol treatment can correct hypokalemia. [8]
  • Benzodiazepine to decrease anxiety, decrease risk of seizures, and help control vomiting
  • Phenylephrine or norepinephrine to further increase blood pressure

Because charcoal hemoperfusion is a somewhat complicated process that is not routinely used lately, most of the centers will perform routine hemodialysis. Hemodialysis in combination with MDAC will most of the time be sufficient for the treatment of severe theophylline toxicity.

Admit all patients with signs and symptoms of toxicity (acute or chronic), or observe them in the ED until their theophylline level decreases and their symptoms have resolved. Admit patients with theophylline levels higher than 30 mcg/mL. Admit patients demonstrating cardiovascular or neurologic dysfunction to the critical care unit.

Consult the regional poison control center or local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations. Consult a nephrologist if hemoperfusion is needed.

For patients with therapeutic theophylline levels and minimal or no toxicity and acute ingestions less than 10 mg/kg, discharge and follow up within 24 hours.  For asymptomatic patients with therapeutic levels following intentional overdose, consider discharge of after psychiatric evaluation.

Prevention

Patients prescribed theophylline who have risk factors for reduced elimination or metabolism of the drug, such as congestive heart failure or liver disease, should be monitored at least every 6 months to avoid significant intoxication.[5]

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

GI decontaminant

Class Summary

GI decontaminants are empirically used to minimize systemic absorption of the toxin. They may only be of benefit if administered within 1-2 h of ingestion.

Activated charcoal (Liqui-Char)

Prevents absorption by adsorbing drug in intestine. Multidose charcoal may interrupt enterohepatic recirculation and enhance elimination by enterocapillary exsorption. Theoretically, by constantly bathing the GI tract with charcoal, the intestinal lumen serves as a dialysis membrane for reverse absorption of drug from intestinal villous capillary blood into intestine. Supplied as an aqueous mixture or in combination with a cathartic (usually sorbitol 70%).

Antiemetics

Class Summary

Persistent vomiting may interfere with decontamination.

Ondansetron (Zofran)

5HT-3 antagonist acting both on the vagus nerve peripherally and at the CTZ in the CNS.

Ranitidine (Zantac)

H2 antagonist that may be a useful adjunct in reducing emesis volume.

Metoclopramide (Reglan)

Works as antiemetic by blocking dopamine receptors in the chemoreceptor trigger zone of the CNS.

Prochlorperazine (Compazine)

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.

In addition to antiemetic effects, has the advantage of augmenting hypoxic ventilatory response, acting as a respiratory stimulant at high altitude.

Droperidol (Inapsine)

Neuroleptic agent that may reduce emesis by blocking dopamine stimulation of chemoreceptor trigger zone.

Benzodiazepines and other sedative agents

Class Summary

These agents are used to terminate seizures and for seizure prophylaxis in high-risk patients. They help to alleviate nausea and vomiting and decrease tremors and anxiety induced by theophylline.

Diazepam (Valium)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.

Lorazepam (Ativan)

Sedative-hypnotic with short onset of effects and relatively long half-life.

By increasing the action of GABA, a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.

Monitoring blood pressure after administering dose is important. Adjust prn.

Midazolam (Versed)

Used as alternative in termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access.

Phenobarbital (Barbita, Luminal)

Interferes with transmission of impulses from thalamus to cortex of brain.

Cardiovascular agents

Class Summary

Alpha-agonists are used to treat persistent hypotension not responding to fluid challenges. Beta-blockers are used for treating severe tachycardia with ischemia or severe hypotension.

Phenylephrine (Neo-Synephrine)

Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles. Increases peripheral venous return.

Esmolol (Brevibloc)

Short-acting IV cardioselective beta-adrenergic blocker with no membrane depressant activity. Half-life of 8 min allows for titration to effect and quick discontinuation prn.

Norepinephrine (Levophed)

For protracted hypotension following adequate fluid-volume replacement. Stimulates beta1- and alpha-adrenergic receptors, which, in turn, increases cardiac muscle contractility and heart rate as well as vasoconstriction. As a result, systemic blood pressure and coronary blood-flow increases.

After obtaining a response, the rate of flow should be adjusted and maintained at a low normal blood pressure, such as 80-100 mm Hg systolic, sufficient to perfuse vital organs.