Theophylline toxicity - Revision history

Mholtz at 23:51, 15 November 2018

2018-11-15T23:51:25Z

← Revisión anterior		Revisión del 23:51 15 nov 2018
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	**Phenobarbital if [[lorazepam]] ineffective		**Phenobarbital if [[lorazepam]] ineffective
	**Phenytoin (Dilantin) contraindicated as increases seizure in animal studies		**Phenytoin (Dilantin) contraindicated as increases seizure in animal studies
	*Dialysis		*Dialysis or plasmapheresis
	**Indicated in [[seizures]], severe [[arrhythmias]]		**Indicated in [[seizures]], severe [[arrhythmias]], hypotension, serum level >90 μg/mL (>40 μg/mL in chronic ingestion)
	**Theophylline level >~~90mcg~~/~~ml in acute ingestion~~
	**Theophylline level >~~40mcg~~/ml in chronic ingestion

	==Disposition==		==Disposition==

Mholtz at 23:48, 15 November 2018

2018-11-15T23:48:05Z

← Revisión anterior		Revisión del 23:48 15 nov 2018
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	==Evaluation==		==Evaluation==
	*Theophylline level		*Theophylline level<ref name="Aggelopoulou">Aggelopoulou, E., Tzortzis, S., Tsiourantani, F., Agrios, I., & Lazaridis, K. (2018). Atrial Fibrillation and Shock: Unmasking Theophylline Toxicity. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 27(4), 387-391.</ref>
			**10–20 μg/mL - Therapeutic
			**20-80 μg/mL - Toxic level
			**80-100 μg/mL - Severe toxicity or death
	*[[ECG]]		*[[ECG]]
	*Metabolic panel		*Metabolic panel
	*Lactic acid level		*Lactic acid level
	*CK		*CK
			*Evaluate for co-ingestion

	==Management==		==Management==
	*Supportive care is the mainstay of treatment		*Supportive care is the mainstay of treatment
	*Cardiovascular		*Cardiovascular
	**~~Consider norepinephrine~~ (alpha-agonist) for hypotension		**Norepinephrine (alpha-agonist) for hypotension resistant to IVF
	**Refractory hypotension may respond to non-selective beta-blockers<ref name="Fisher" />		**Refractory hypotension may respond to non-selective beta-blockers<ref name="Fisher" />
			**Beta-blockers (esmolol preferred due to short half-life) for tachydysrhythmias
	*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])		*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])
	**Consider in recent severe overdose		**Consider in recent severe overdose
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	==Disposition==		==Disposition==
	~~===Immediate release===~~		*Almost all patients will require admission
	*~~Home after 6 hours~~ if:		*Can consider discharge with close followup (in conjunction with toxicology) if unintentional overdose, asymptomatic, and normal vital signs
	**nontoxic
	**asymptomatic
	**and, ~~normal vital sign~~

	~~===Sustained release===~~
	*Home after 12 hours if:
	**nontoxic
	**asymptomatic
	**and, normal vital ~~sign~~

	==See Also==		==See Also==

Mholtz at 23:27, 15 November 2018

2018-11-15T23:27:40Z

← Revisión anterior		Revisión del 23:27 15 nov 2018
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	**[[Sinus Tachycardia]]		**[[Sinus Tachycardia]]
	**Atrial/Ventricular [[arrhythmias]]		**Atrial/Ventricular [[arrhythmias]]
	**[[Hypotension]] (~~2/2~~ β2-mediated vasodilation)		**[[Hypotension]] (due to β2-mediated vasodilation)
	*Metabolic		*Metabolic
	**[[Hypokalemia]]		**[[Hypokalemia]]
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	==Management==		==Management==
	*Supportive care		*Supportive care is the mainstay of treatment
	**Cardiac monitoring
	**Ondansetron (Zofran) for antiemetic
	**EEG for sedated and paralyzed patients
	*Cardiovascular		*Cardiovascular
	**~~[[IV Fluids]]~~ for [[hypotension]]		**Consider norepinephrine (alpha-agonist) for hypotension
	**~~Beta~~ blockers ~~for [[tachyarrhymias]]~~		**Refractory hypotension may respond to non-selective beta-blockers<ref name="Fisher" />
	***[[Esmolol]] particularly wise first-line agent
	***Controversial, involve a toxicologist
	*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])		*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])
	**~~Considered~~ in ~~life-threatening~~ overdose		**Consider in recent severe overdose
	***contraindications: unsecured airway, [[nausea]], [[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy		**Contraindications: unsecured airway, [[nausea]]/[[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy
	*[[Seizures]]		*[[Seizures]]
	**[[Lorazepam]] (Ativan) 1st line		**[[Lorazepam]] (Ativan) 1st line

Mholtz at 22:34, 15 November 2018

2018-11-15T22:34:40Z

← Revisión anterior		Revisión del 22:34 15 nov 2018
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	''See [[theophylline]] for general drug information.''		''See [[theophylline]] for general drug information.''
	==Background==		==Background==
	*~~Still~~ used ~~in patients with debilitating brochospastic disease~~		*Primarily used as a bronchodilator, however rarely used now due to better available options
	*~~Studied~~ for treatment of [[Acute Mountain Sickness]] and [[Contrast-Induced Nephropathy]]		*Also studied for treatment of [[Acute Mountain Sickness]] and [[Contrast-Induced Nephropathy]]
	*PO ~~in elixir,~~ extended release~~, or controlled release forms but absorption erratic~~		*PO available as elixer and capsule (12 or 24-hour extended release)
	*IV as aminophylline		*IV as aminophylline (shorter acting than PO)
	*~~Adenosine antagonism~~, ~~Increase catecholamines~~, and ~~Phosphodiesterase~~ inhibition		*Mechanism of action<ref name="Fisher">Fisher, J., & Graudins, A. (2015). Intermittent haemodialysis and sustained low-efficiency dialysis (SLED) for acute theophylline toxicity. Journal of medical toxicology : official journal of the American College of Medical Toxicology, 11(3), 359-63.</ref>:
			**Release of endogenous catecholamines → β2 agonism → bronchodilation
			**PDE inhibition → increases cAMP
			**Adenosine antagonist

	==Clinical Features==		==Clinical Features==
	*Neurologic
	**Tremor
	**Agitation
	**[[Seizure]]
	*Cardiovascular		*Cardiovascular
	**[[Sinus Tachycardia]]		**[[Sinus Tachycardia]]
	**Atrial/Ventricular [[arrhythmias]]		**Atrial/Ventricular [[arrhythmias]]
	**[[Hypotension]]		**[[Hypotension]] (2/2 β2-mediated vasodilation)
	*Metabolic		*Metabolic
	**[[Hypokalemia]]		**[[Hypokalemia]]
	**[[Metabolic Acidosis]]		**[[Metabolic Acidosis]]
	**[[Hyperthermia]]		**[[Hyperthermia]]
	**[[Rhabdomyolysis]]
	**[[Hyperglycemia]]		**[[Hyperglycemia]]
			*Neurologic
			**Tremor
			**Agitation
			**[[Seizure]]
	*GI		*GI
	**[[Nausea/Vomiting]]		**[[Nausea/Vomiting]]
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	==Evaluation==		==Evaluation==
			*Theophylline level
	*[[ECG]]		*[[ECG]]
	*~~Chem~~		*Metabolic panel
			*Lactic acid level
	*CK		*CK
	*Theophylline level

	==Management==		==Management==

Mholtz at 19:01, 15 November 2018

2018-11-15T19:01:45Z

← Revisión anterior		Revisión del 19:01 15 nov 2018
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	==Management==		==Management==
	#Supportive care		*Supportive care
	#*Cardiac monitoring		**Cardiac monitoring
	#*Ondansetron (Zofran) for antiemetic		**Ondansetron (Zofran) for antiemetic
	#*EEG for sedated and paralyzed patients		**EEG for sedated and paralyzed patients
	#Cardiovascular		*Cardiovascular
	#*[[IV Fluids]] for [[hypotension]]		**[[IV Fluids]] for [[hypotension]]
	#*Beta blockers for [[tachyarrhymias]]		**Beta blockers for [[tachyarrhymias]]
	#**[[Esmolol]] particularly wise first-line agent		***[[Esmolol]] particularly wise first-line agent
	#**Controversial, involve a toxicologist		***Controversial, involve a toxicologist
	#GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])		*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])
	#*Considered in life-threatening overdose		**Considered in life-threatening overdose
	#**contraindications: unsecured airway, [[nausea]], [[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy		***contraindications: unsecured airway, [[nausea]], [[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy
	#[[Seizures]]		*[[Seizures]]
	#*[[Lorazepam]] (Ativan) 1st line		**[[Lorazepam]] (Ativan) 1st line
	#*Phenobarbital if [[lorazepam]] ineffective		**Phenobarbital if [[lorazepam]] ineffective
	#*Phenytoin (Dilantin) contraindicated as increases seizure in animal studies		**Phenytoin (Dilantin) contraindicated as increases seizure in animal studies
	#Dialysis		*Dialysis
	#*Indicated in [[seizures]], severe [[arrhythmias]]		**Indicated in [[seizures]], severe [[arrhythmias]]
	#*Theophylline level >90mcg/ml in acute ingestion		**Theophylline level >90mcg/ml in acute ingestion
	#*Theophylline level >40mcg/ml in chronic ingestion		**Theophylline level >40mcg/ml in chronic ingestion

	==Disposition==		==Disposition==
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	==External Links==		==External Links==


	==References==		==References==
	<references/>		<references/>

	[[Category:Toxicology]]		[[Category:Toxicology]]

Kxl328: /* Management */

2018-11-09T04:22:01Z

Management

← Revisión anterior		Revisión del 04:22 9 nov 2018
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	#*[[IV Fluids]] for [[hypotension]]		#*[[IV Fluids]] for [[hypotension]]
	#*Beta blockers for [[tachyarrhymias]]		#*Beta blockers for [[tachyarrhymias]]
			#**[[Esmolol]] particularly wise first-line agent
	#**Controversial, involve a toxicologist		#**Controversial, involve a toxicologist
	#GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])		#GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])

Mholtz: Text replacement - "==References== " to "==References== "

2017-07-24T01:12:23Z

Text replacement - "==References== " to "==References== <references/> "

← Revisión anterior		Revisión del 01:12 24 jul 2017
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	==References==		==References==
			<references/>
	[[Category:Toxicology]]		[[Category:Toxicology]]

Rossdonaldson1 at 22:27, 20 September 2016

2016-09-20T22:27:45Z

← Revisión anterior		Revisión del 22:27 20 sep 2016
Línea 1:		Línea 1:
	''See [[theophylline]] for general drug information''		''See [[theophylline]] for general drug information.''
	==Background==		==Background==
	*Still used in patients with debilitating brochospastic disease		*Still used in patients with debilitating brochospastic disease

Rossdonaldson1: /* Management */

2016-09-20T22:26:39Z

Management

← Revisión anterior		Revisión del 22:26 20 sep 2016
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	==Management==		==Management==
	*GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])		#Supportive care
	**Considered in life-threatening overdose		#*Cardiac monitoring
	***contraindications: unsecured airway, [[nausea]], [[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy		#*Ondansetron (Zofran) for antiemetic
	*[[Seizures]]		#*EEG for sedated and paralyzed patients
	**[[Lorazepam]] (Ativan) 1st line		#Cardiovascular
	**Phenobarbital if [[lorazepam]] ineffective		#*[[IV Fluids]] for [[hypotension]]
	**Phenytoin (Dilantin) contraindicated as increases seizure in animal studies		#*Beta blockers for [[tachyarrhymias]]
	*Cardiovascular		#**Controversial, involve a toxicologist
	**[[IV Fluids]] for [[hypotension]]		#GI decontamination ([[Multidose Activated Charcoal]], [[Whole Bowel Irrigation]])
	**Beta blockers for [[tachyarrhymias]]		#*Considered in life-threatening overdose
	***Controversial, involve a toxicologist		#**contraindications: unsecured airway, [[nausea]], [[vomiting]], ileus, [[Bowel Obstruction]], or need for emergent endoscopy
	*Dialysis		#[[Seizures]]
	**Indicated in [[seizures]], severe [[arrhythmias]]		#*[[Lorazepam]] (Ativan) 1st line
	**Theophylline level >90mcg/ml in acute ingestion		#*Phenobarbital if [[lorazepam]] ineffective
	**Theophylline level >40mcg/ml in chronic ingestion		#*Phenytoin (Dilantin) contraindicated as increases seizure in animal studies
	*Supportive care		#Dialysis
	**Cardiac monitoring		#*Indicated in [[seizures]], severe [[arrhythmias]]
	**Ondansetron (Zofran) for antiemetic		#*Theophylline level >90mcg/ml in acute ingestion
	**EEG for sedated and paralyzed patients		#*Theophylline level >40mcg/ml in chronic ingestion

	==Disposition==		==Disposition==

Rossdonaldson1: /* Differential Diagnosis */

2016-09-20T22:25:24Z

Differential Diagnosis

← Revisión anterior		Revisión del 22:25 20 sep 2016
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	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Beta-2 agonist]] ~~use~~		*[[Beta-2 agonist]] toxicity
	*[[Sympathomimetic toxicity]]		*[[Sympathomimetic toxicity]]
	*[[Iron toxicity]]		*[[Iron toxicity]]