title: Case Report: The risks associated with chronic theophylline therapy and measures designed to improve monitoring and management.
abstract: BACKGROUND
  Symptoms of theophylline toxicity and factors that augment the risk of developing it are well documented in the literature. However these appear to be poorly considered in clinical practice. This case underlines the challenges in recognising and managing theophylline toxicity; moreover the requirement for improved application of knowledge of its pharmacokinetics to our practice.
  
  
  METHODS
  In this case we observe how theophylline toxicity can be overlooked due to the presence of non-specific symptoms and lack of a structured system to mitigate error in detection, in both hospital medicine and general practice. Here, the initial theophylline concentration measurement was documented as 59.3 mg/l in a patient taking the medication long-term, with the previous concentration being recorded one year prior. Management consisted of suspension of theophylline along with best supportive care, however in the process other conditions were exacerbated and the patient ultimately died in hospital. Congestive cardiac failure, congestive liver disease and polypharmacy were factors isolated from this case that expedited the patients' development of theophylline toxicity. This was perpetuated by delay in diagnosis due to presentation with generalised symptoms including tachycardia, vomiting and neurological symptoms.
  
  
  CONCLUSIONS
  Findings from this case necessitate a requirement for more stringent monitoring of theophylline when taken chronically in those who demonstrate risk factors for toxicity. This would aim to prevent accumulation of the drug, toxicity onset and subsequent acute presentation to hospital. Intervention, through charcoal haemoperfusion may provide a means of enhanced recovery to reduce sequelae of toxicity.
authors.affiliation: Foundation Year 1 Doctor. Royal United Hospital NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK. michael.hopkins2@nhs.net.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Hopkins
authors.affiliation: Consultant Respiratory Physician. Royal United Hospital NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK. rob.mackenizeross@nhs.net.
authors.forename: Robert V
authors.initials: RV
authors.lastname: MacKenzie-Ross
mesh_terms: D001993:Bronchodilator Agents / Q000009:adverse effects* / Q000097:blood / Q000493:pharmacokinetics; D003131:Combined Modality Therapy; D057210:Delayed Diagnosis; D004347:Drug Interactions; D016903:Drug Monitoring; D004359:Drug Therapy, Combination / Q000009:adverse effects; D017809:Fatal Outcome; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy; D006801:Humans; D007866:Leg; D017093:Liver Failure / Q000150:complications / Q000188:drug therapy; D008875:Middle Aged; D020258:Neurotoxicity Syndromes / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D010523:Peripheral Nervous System Diseases / Q000209:etiology; D019338:Polypharmacy; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000188:drug therapy*; D012640:Seizures / Q000209:etiology; D013610:Tachycardia / Q000209:etiology; D013806:Theophylline / Q000009:adverse effects* / Q000097:blood / Q000493:pharmacokinetics
chemical_list: D001993:Bronchodilator Agents; D013806:Theophylline