Therapeutic Theophylline Concentrations Research Articles

Serum Theophylline Concentrations in very Preterm Neonates Receiving Intravenous Aminophylline for Apnea

Objective: To determine the percentage of neonates who achieved therapeutic theophylline level (TTL) after receiving standard IV loading/maintenance aminophylline doses. To assess factors associated with achieving therapeutic theophylline concentrations and to describe adverse effects of aminophylline. Materials and Methods: This was a pilot, cross-sectional study. Preterm neonates ≤34 weeks’ gestation for which aminophylline was indicated for treatment of apnea were enrolled. Standard IV aminophylline dosage is 8 mg/ kg loading dose, followed by 1.5 mg/kg maintenance dose every 8 hours. Serum theophylline concentrations were measured prior to the 8th maintenance dose. Descriptive statistics, univariate and multivariate analyses were performed. Results: Twenty-five neonates (52% female) were enrolled: mean (standard deviation) gestational age and birth weight were 30.4 (2) weeks and 1,277 (415) grams, respectively. Aminophylline was initiated at a median (25%tile, 75%tile) postnatal age of 4 (1, 8) days. Baseline heart rate prior to the loading dose was 153 (13) beats-per-minute. Sixty percent of neonates achieved a therapeutic theophylline level. In the univariate analysis, being male and postnatal age ≤5 days were associated with successfully achieving a TTL. After adjusting for gender, postnatal age ≤5 days was the only factor associated with achieving a TTL (adjusted odds ratio 17.7, 95% confidence interval: 1.9, 164.4). Tachycardia and feeding intolerance were observed in 44% and 24% of neonates, respectively. Conclusion: Current IV aminophylline dosing conditions in Thailand achieved TTL in approximately two-thirds of neonates, suggesting therapeutic drug monitoring is beneficial for guiding dosing. A higher maintenance dose could be considered for neonates older than 5 days.

Theophylline and Dexamethasone Induce Peroxisome Proliferator-Activated Receptor-γ Expression in Human Eosinophils

Eosinophils are major effector cells in allergic diseases including asthma. Peroxisome proliferator-activated receptor-γ (PPARγ) is a nuclear receptor that regulates immune reaction. We have previously demonstrated that human eosinophils express PPARγ and that stimulation with a synthetic agonist for PPARγ attenuated the factor-induced eosinophil survival and chemotaxis. However, the modulator of the eosinophil PPARγ expression has not yet been studied. In this study, we investigated the effect of theophylline and dexamethasone (widely used drugs in the treatment of asthma) on PPARγ expression in eosinophils. Purified human peripheral blood eosinophils were cultured, and therapeutic concentrations of theophylline and dexamethasone were added. Subsequently, PPARγ was measured using quantitative real-time RT-PCR and flow cytometry. Theophylline and dexamethasone markedly enhanced both mRNA and protein levels of PPARγ. These findings suggest that the increase in PPARγ expression on eosinophils may play a role in the anti-inflammatory effects of theophylline and dexamethasone.

Involvement of A3 receptors in the potentiation by adenosine of the inhibitory effect of theophylline on human eosinophil degranulation: possible novel mechanism of the anti-inflammatory action of theophylline

The current use of theophylline in asthma is based on both the bronchodilatory and the anti-inflammatory effects. The exact mechanism of these actions is still controversial and may include the inhibition of adenosine 3′,5′-monophosphate phosphodiesterase enzyme (PDE) and antagonism of adenosine receptors. In this study, the mechanism of the anti-inflammatory action was investigated by studying the inhibition by theophylline of complement C5a (C5a)-induced degranulation of human eosinophils and its interaction with adenosine. Theophylline (10–1000 μM) inhibited C5a-induced release of eosinophil peroxidase (EPO) in a concentration-dependent manner with an ic50 of 233.5 μM and a maximal inhibition of 90.3 ± 3.0%. In contrast, the PDE4 inhibitor rolipram (up to 50 μM) had no effect. The adenosine A3 receptor agonist N6-(3-iodobenzyl)-5′-N-methylcarbamoyladenosine (IB-MECA) also inhibited release (ic50 = 7.5 μM), but neither adenosine itself nor the selective A1 and A2 agonists and antagonists had any significant effect, even at 100 μM. The inhibition produced by clinically relevant concentration of theophylline (50 μM) was potentiated by ineffective concentrations of exogenous adenosine and additive to that produced by IB-MECA. The potent and selective A3 antagonist MRS 1220, but not the A1 or A2 antagonists, significantly reversed the inhibitory effect of theophylline. These results suggest that therapeutic concentrations of theophylline inhibit human eosinophil partly by acting as an A3 agonist. Together with the potentiation of theophylline action by adenosine, perhaps via the A3 receptors, these novel actions may, at least in part, contribute to the mechanism of the anti-inflammatory action of this drug in vivo.

Effects of theophylline, dexamethasone and salbutamol on cytokine gene expression in human peripheral blood CD4+ T-cells.

CD4+ T-cells are considered as pivotal in orchestrating the airway inflammation in asthma through the actions of their cytokines. Current hypothesis suggests that the anti-asthma effect of theophylline may be due to its anti-inflammatory actions, although the exact mechanisms remain unclear. The in vitro effect of theophylline on cytokine gene expression in peripheral blood CD4+ T-cells in normal subjects was compared with that of dexamethasone and salbutamol. CD4+ T-cells were cultured with phytohaemagglutin and phorbol myristate acetate in the presence of different concentrations of theophylline (10(-8)-10(-3) M or 0.0018-180 microg x mL(-1)) in one group of subjects (n=8), dexamethasone (10(-9)-10(-6) M or 0.39-390 ng x mL(-1)) in a second group (n=8) and salbutamol (10(-9)-10(-4) M or 0.00058-58 microg x mL(-1)) in a third group (n=8). Gene expression of interleukin (IL)-3, IL-4, IL-5, granulocyte-macrophage colony-stimulating factor (GM-CSF) and interferon (IFN)-gamma was semiquantified by reverse transcription-polymerase chain reaction. Suppressed expression of IL-3 (36.9%), IL4 (38.8%), GM-CSF (24.6%) and IFN-gamma (37.7%), but not of IL-5, was only seen with theophylline at a concentration of 10(-3) M (180 microg x mL(-1)) (p<0.05) and not at lower concentrations. In contrast, dexamethasone caused a dose-dependent suppression of transcription of all cytokines, with 39.5% for IL-3, 84.4% for IL-4, 40.6% for IL-5, 50.9% for GM-CSF and 31.8% for IFN-gamma at 10(-6) M (390 ng x mL(-1)) (p<0.05-0.001). Salbutamol did not suppress gene expression of any of the cytokines at the concentrations examined. These data suggest that cytokine gene expression of CD4+ T-cells is not affected at therapeutic concentrations of theophylline and salbutamol, but its suppression is likely to be an important mechanism underlying the therapeutic effect of corticosteroids in asthma.

Theophylline Delays Skeletal Muscle Fatigue during Progressive Exercise

In this study, 31P nuclear magnetic resonance spectroscopy (NMRS) was used to examine the effect of theophylline on human forearm muscle metabolism during progressive exercise. Six healthy men (37 +/- 14 yr of age) were assigned to either a control (CTRL) group (n = 3), or a theophylline treatment (THEO) group (n = 3). Each subject performed two dynamic wrist flexion exercise tests to fatigue, with at least 72 h separating each trial. The THEO group repeated the protocol after receiving 300 mg of sustained-release theophylline every 12 h. 31P spectra were acquired every 36 s throughout exercise, and the relative contributions of the phosphate metabolites and pH were determined. Power output at the onset, or threshold of intracellular acidosis (IT), was identified for each subject from changes in phosphocreatine (PCr) metabolism and pH. Power at maximal exercise and at the IT was found to be reproducible in the CTRL group. After theophylline administration, the maximal power attained by the THEO group increased significantly by 19% (p < 0.05), from 2.25 +/- 0.2 to 2.68 +/- 0.15 W. A similar trend occurred in the onset of the IT, which was also prolonged by 19%, from 1.33 +/- 0.18 to 1.58 +/- 0.22 W. Therapeutic concentrations of theophylline significantly increased the endurance of the forearm musculature, apparently by delaying the onset of intracellular metabolic acidosis. These findings suggest an enhancement of oxidative capacity of the muscle.

Aminophylline in the Emergency Department: Maximizing Safety and Efficacy

An experimental technique designed to predict theophylline doses needed to attain therapeutic theophylline concentrations in 43 emergency department (ED) patients was compared with a standard conventional regimen in 46 ED patients. The experimental protocol utilized a computer-assisted dosage prediction program that incorporated baseline theophylline concentration rapidly obtained using a bedside assay. The standard protocol used conventional loading and infusion rates, as well as an estimate of time of last theophylline dose based on patient history. Plasma theophylline concentrations, estimated 1 and 6 hours after commencement of aminophylline therapy in each regimen, were compared. The experimental protocol was equally rapid but much more accurate in achieving targeted theophylline concentrations. Experimental dosage prediction was associated with a higher proportion of theophylline concentrations in the therapeutic range at 1 (81 percent vs 26 percent; p less than 0.001) and 6 hours (91 percent vs 37 percent; p less than 0.001). There was a trend toward fewer toxic concentrations recorded at 1 (0 percent vs 7 percent; p = 0.27) and 6 hours (0 percent vs 10 percent; p = 0.08). This protocol, which was performed quickly and without difficulty by residents in a busy hospital ED, offers an opportunity to improve the efficacy and decrease the toxicity of theophylline use in asthma emergencies.

COMPARISON OF THEOPHYLLINE AND ENPROFYLLINE EFFECTS ON HUMAN NEUTROPHIL SUPEROXIDE PRODUCTION

1. We investigated effects of theophylline (widely used for the treatment of asthma) and enprofylline (a new xanthine derivative with negligible adenosine antagonism) on O2- production by human neutrophils with n-formyl-methionyl-leucyl-phenylalanine (FMLP) stimulation. 2. Therapeutic concentrations of theophylline (1-100 mumol/L) enhanced O2- production, maximally by 43.1 +/- 24.4% at 30 mumol/L; the same concentrations of enprofylline inhibited O2- production. 3. When each agent was administered after pre-incubation with adenosine deaminase (ADA) (0.1 U/mL), O2- production was inhibited in a concentration-dependent manner in comparison with that under administration of ADA alone. 4. These results suggest that the difference of effects in the two xanthine derivatives at therapeutic concentrations might be due to the presence or absence of adenosine antagonism.

Effect of Theophylline and Adenosine on Eosinophil Function

Eosinophils may play a critical role in asthma and bronchial hyperresponsiveness, yet the effect of theophylline on their function is not certain. We have examined the effects of theophylline on opsonized zymosan-induced superoxide anion (O2-) release from guinea pig eosinophils harvested from the peritoneal cavity and from human eosinophils obtained by differential centrifugation of blood from patients with peripheral eosinophilia. Theophylline at high concentration (10(-3) M) inhibited O2- release by 27.6 +/- 9.4% (mean +/- SEM, p less than 0.05), whereas at clinically relevant concentrations (10(-6) and 10(-5) M), it significantly potentiated this by 26.8 +/- 9.9% (p less than 0.05) and 36.9 +/- 6.3% (p less than 0.01), respectively. 8-phenyltheophylline (10(-7) to 10(-3) M), which like theophylline inhibits adenosine receptors but does not inhibit phosphodiesterase activity, produced potentiation at all concentrations. Preincubation of eosinophils with adenosine deaminase (0.1 U/ml) enhanced O2- release by 72.4 +/- 15.2% (p less than 0.01), whereas addition of adenosine (3 x 10(-8) to 10(-6) M) reversed the potentiation induced by theophylline (10(-5) M) in a concentration-dependent manner. Inhibition was greater with the A2-selective analog N-ethylcarboxamide adenosine than the A1-selective analog phenylisopropyladenosine, suggesting that A2-receptors are involved. In human eosinophils we have demonstrated a similar effect of theophylline and adenosine on O2- release. Our results indicate that therapeutic concentrations of theophylline may potentiate eosinophil activation in vivo by competing with circulating adenosine for eosinophil A2-receptors. This would be consistent with the lack of effect of theophylline on bronchial hyperresponsiveness, which may be related to eosinophilic inflammation.

Polymorphonuclear Leukocyte Inhibition by Therapeutic Concentrations of Theophylline Is Mediated by Cyclic-3′, 5′-Adenosine Monophosphate

Although theophylline has been used for many years as a principal agent in treatment of reversible obstructive airway disease, the mechanism of drug activity at therapeutic concentrations remains unclear. Because inflammatory mediators generated by polymorphonuclear leukocytes (PMN) may be important in the pathogenesis of airway hyperreactivity, the effects of theophylline upon PMN activation were studied. Theophylline (9 micrograms/ml, 50 microM) inhibited PMN leukotriene B4 generation by 50%, oxygen metabolite generation by 60%, and decreased the concentration of isoproterenol required to cause 50% maximal inhibition (EC50) from 13 to 3.3 nM. The same theophylline concentration increased PMN cAMP by 196% at 45 s after cell activation. A higher theophylline concentrations (18 micrograms/ml, 100 microM) decreased leukotriene B4 generation by more than 90%. Eight healthy volunteers were studied before and after 1 wk of oral theophylline administration (mean plasma theophylline level achieved was 9.4 micrograms/ml). Basal and 1-min postactivation cAMP concentrations were increased 160 and 157%, respectively, in PMN specimens after theophylline administration. The EC50 for isoproterenol was reduced by 50%, and the cAMP elevation induced by isoproterenol was increased by 200%. Because theophylline inhibition of PMN function appeared to be associated with both an increase in cAMP and a decrease in intracellular calcium, these effects may be relevant to both the therapeutic and adverse pharmacologic actions of theophylline. Because inflammatory mediator release was reduced by low drug concentrations, inhibition of PMN function may be an effect of therapeutic theophylline administration.

Automated determination of drugs in serum by columnswitching high-performance liquid chromatography II. Separation of theophylline and its metabolites

The automated determination of theophylline and related compounds in human serum by columnswitching high-performance liquid chromatography, including direct injection of serum samples, is described. TSK pre-column BSA-ODS and TSK gel ODS-80TM were used in the pre-column and analytical column, respectively. Serum samples of 20, μl were directly injected on to the pre-column. After washing out serum proteins from the pre-column with 0.1 M NaH 2PO 4 at a flow-rate of 1.0 ml/min for 3.5 min, the effluent from the pre-column was introduced on to the analytical column by a column-switching device. The analysis was performed by stepwise gradient elution using 10 and 18% methanol in 0.1 M NaH 2PO 4. Theophylline and nine derivatives could be determined simultaneously within 40 min. The recovery of these compounds from serum was 95–103%. The linearity (1.0–50, μ/ml theophylline) and reproducibility (coefficient of variation less than 2.0%) were sufficient for drug monitoring at the lower and upper limits of therapeutic concentrations of theophylline.

Concentration-dependent interaction of theophylline with d-tubocurarine.

The interaction of theophylline with d-tubocurarine chloride (dTC) was examined in rabbits. After steady-state subtherapeutic (less than 10 mg/l), therapeutic (10-20 mg/l), and toxic (greater than 20 mg/l) concentrations of theophylline, dose-response curves for dTC were determined and compared with controls that received no theophylline. At therapeutic concentrations of theophylline the effective dose for 50% inhibition of twitch (ED50) for dTC (mean +/- SE, 0.115 +/- 0.016 mg/kg) was significantly shifted to the left in comparison with the control (0.165 +/-0.008 mg/kg). The ED50 of dTC for the subtherapeutic group was 0.143 +/- 0.011 mg/kg, which was less than the control but not of statistical significance (P = 0.1). The ED50 for the toxic theophylline group was 0.168 +/- 0.003 mg/kg, which was not significantly different from controls but significantly different from the theophylline therapeutic and subtherapeutic groups. Thus, toxic concentrations of theophylline reversed the potentiating effects of therapeutic and subtherapeutic concentrations of dTC dose-response curves. Therefore, depending on concentration, theophylline exhibits a biphasic interaction with dTC. Surgical patients on theophylline may require less dTC intraoperatively. More importantly, the use of theophylline in the postoperative period to reverse anesthetic effects may result in recurarization.

Therapeutic concentrations of theophylline and enprofylline potentiate catecholamine effects and inhibit leukocyte activation

Methylxanthines are primary agents used in treatment of hypersensitivity disease. Because polymorphonuclear leukocyte (PMN) activation is associated with generation of potent inflammatory mediators, xanthine effects on the PMN respiratory burst were studied. Enprofylline, a xanthine with important therapeutic potential, does not antagonize adenosine and was contrasted with theophylline. Although enprofylline was more potent at low concentrations, both drugs exhibited dose-dependent inhibition of PMN activation at concentrations >10 μmol/L (1.8 μg/ml). Oxygen metabolite generation was decreased by 30% to 40% at therapeutic drug concentrations and by 85% at 1 mmol/L of theophylline. Inhibition by isoproterenol or prostaglandin E 2 but not dibutyryl cAMP was potentiated by either xanthine. Isoproterenol effects were also increased when isoproterenol was evaluated in whole blood specimens obtained from subjects after a loading dose of aminophylline. Although these results were most compatible with cAMP phosphodiesterase inhibition, other commonly proposed mechanisms of methlxanthine activity were also studied. Theophylline but not enprofylline blocked adenosine inhibition of PMN activation. Neither xanthine shifted the calcium dose-response when PMNs were activated with calcium ionophore. Because oxygen metabolites generated by the PMN are mediators of inflammation and hypersensitivity, direct inhibition of PMN activation as well as potentiation of catecholamine activity may be important therapeutic effects of theophylline and enprofylline.

Effect of aminophylline on the human diaphragm.

The effect of intravenous aminophylline on the contractile function of the diaphragm was studied in four normal subjects. The contractility of the diaphragm was assessed by the measurement of transdiaphragmatic pressure (Pdi) after right phrenic nerve stimulation at 1 Hz. Pdi was measured before and during aminophylline infusion (6 mg/kg over 30 minutes), during which therapeutic concentrations of theophylline were attained (mean 13.8 mg/l, range 8.5-20.2). The Pdi achieved was not affected by aminophylline. This result suggests that theophylline at therapeutic concentrations has little effect on the contractility of the normal human diaphragm.

Inadequacy of FDA dosing guidelines for intravenous theophylline.

The ability of a dosing regimen of intravenous theophylline to achieve therapeutic serum theophylline concentrations was evaluated. Intravenous theophylline was administered to 25 adult patients with acute bronchospasm using dosing guidelines 20 percent higher than FDA recommendations. The dose of theophylline was determined by assignment to one of four clinical categories. Blood samples for determination of serum theophylline concentrations were collected 12 and 24 hours after initiation of a constant infusion. Differences between mean observed and target theophylline concentrations did not achieve statistical significance. All patients in categories 1 and 2 achieved therapeutic concentrations of theophylline. Most of those with subtherapeutic levels were smokers suffering from multiple diseases. We conclude that current FDA recommendations for dosing intravenous theophylline are unreliable for routine use in category 3 and 4 patients. Further work is necessary to evaluate these recommendations in pediatric and category 1 and 2 patients.

Theophylline increases serum uric acid levels

The present study was undertaken to investigate the effect of theophylline on serum uric acid and then to elucidate the mechanisms of action of theophylline as a cause of hyperuricemia. There was a significant increase of serum uric acid levels in male asthmatic patients who received theophylline compared to male control subjects without theophylline (6.3 ± 0.4 mg/ml, mean ±SEM, versus 4.3 ± 0.2 mg/ml, p < 0.01). A significant correlation of serum levels of uric acid and theophylline was demonstrated in asthmatic patients who received 200 to 400 mg sustained-release theophylline (male group, r = 0.480, p < 0.001; female group, r = 0.398, p < 0.01). Intravenous administration of aminophylline in three healthy adult male patients did not inhibit uric acid clearance, suggesting that inhibition of excretion of uric acid by theophylline is unlikely. Theophylline slightly inhibited hypoxanthine guanine phosphoribosyltransferase activity in human erythrocyte lysates at concentrations over 5 mM that is considerably more than therapeutic concentrations of theophylline as determined by the conversion of [ 14 C]hypoxanthine to [ 14 C]inosinic acid. Theophylline caused a moderate inhibition of [ 14 C]hypoxanthine uptake by K-562 cells (~50%) at 10mM that is over 100 times as high as those achieved clinically. Further studies remain to be performed to elucidate the exact mechanisms of theophylline-induced hyperuricemia.

Idiopathic apnoea of prematurity treated with doxapram and aminophylline.

Doxapram infusion was given to five preterm infants in whom therapeutic concentrations of theophylline had failed to control episodes of apnoea. Doxapram successfully controlled the apnoea, the arterial blood PCO2 value decreased significantly, and no side effects were reported.

Universal adenosine receptor antagonism is neither necessary nor desirable with xanthine antiasthmatics

The great diversity of pharmacological effects of xanthines may well reflect different cellular mechanisms of action. Major attention is presently devoted to adenosine receptor antagonism that, in contrast to phosphodiesterase inhibition, is clearly produced by therapeutic concentrations of theophylline. The ubiquitous adenosine effects together with the universal and potent blocking action of methylxanthines have led investigators to believe that most pharmacological actions including antiasthmatic effects of theophylline reflect adenosine antagonism. The present hypothesis proposes that universal adenosine receptor antagonism is neither necessary nor desirable with xanthine antiasthmatics. Supporting the hypothesis a xanthine derivative that seems to be devoid of functional effects at important adenosine receptor sites has been shown to be a potent bronchodilator drug that lacks theophylline-like diuretic and CNS-stimulant behavioural effects.

Peritoneal dialysis in rabbits. A study of transperitoneal theophylline flux and peritoneal permeability.

Since vasodilators can restore toward normal the decreased peritoneal clearances associated with vascular disease, the influence of aminophylline on peritoneal solute transport was studied in unanesthetized rabbits. Mean control creatinine clearance was 0.56 ml/kg/min and urea clearance 0.80 ml/kg/min. Neither intraperitoneal nor intravenous aminophylline increased peritoneal clearances, nor did the ratio creatinine clearance/urea clearance change from the control value, 0.70. Bidirectional flux of theophylline occurred at clearances of 0.70 ml/kg/min efflux and 0.64 ml/min influx. The removal rate of theophylline was 0.05% min, allowing therapeutic removal of excess aminophylline and warranting supplemental therapy during dialysis if therapeutic theophylline concentrations are required. As the intraperitoneal aminophylline was well tolerated, this route can be considered for therapeutic administration.

Plasma level and broncholytic effect of choline theophyllinate after a single dose of a press-coated tablet formulation.

The broncholytic effect and plasma concentrations of theophylline in 10 asthmatic patients were studied for 8 hours after a single dose of 600 mg choline theophyllinate in press-coated 200 mg tablets. Therapeutic concentrations of theophylline were rapidly achieved and the plasma peak averaged 10.4 mug/ml after 2 hours. The broncholytic effect was closely related to the plasma level of theophylline. The largest change was in FEV1, which was significantly increased 1 to 6 hours after the dose. No patient complained of adverse effects. A theophylline concentration of 7 mug/ml plasma was adequate for a broncholytic effect, but a higher level was required for a maximal response. The results provide a basis for further studies to establish a dosage schedule suitable for prolonged therapy.