Intermittent haemodialysis and sustained low-efficiency dialysis (SLED) for acute theophylline toxicity

Abstract

Introduction Theophylline overdose can result in significant cardiovascular and neurologic toxicity and is potentially fatal. Clearance of theophylline can be enhanced by the administration of multiple-dose activated charcoal (MDAC) and extracorporeal elimination techniques. We report a case of severe theophylline toxicity initially treated with MDAC and intermittent haemodialysis. Subsequent to this, sustained lowefficiency dialysis (SLED) was undertaken. This is a prolonged renal replacement therapy that uses blood and dialysate flow rates between those of intermittent haemodialysis and continuous renal replacement therapy. Case report A 61-year-old man presented following ingestion of 24 g of theophylline SR (300 mg/kg), 240 mg of diazepam and 2 g of gabapentin. He required intubation and developed a supraventricular tachycardia treated with esmolol, but suffered no seizures. Serum theophylline concentration peaked at 636 μmol/L (55-110) at 9.5 h post-ingestion. Intermittent haemodialysis was performed for 4 h and resulted in a theophylline extraction ratio of 0.57 with elimination half-life of 2.3 h. SLED was subsequently performed on two occasions for 7 h. Theophylline extraction ratio ranged from 0.46 (halflife 5.3 h during the first cycle) to 0.61 (half-life 10.6 h during the second cycle). After cessation of SLED, elimination halflife was 26 h. The patient made an uneventful recovery. Discussion Intermittent haemodialysis is the current recommended extracorporeal technique for enhancing theophylline elimination in the absence of charcoal haemoperfusion. However, SLED produced similar apparent extraction ratios with longer associated elimination half-life for theophylline than for intermittent haemodialysis. SLED is undertaken by intensive care unit (ICU) staff and may be a useful extracorporeal elimination technique in cases where access to intermittent haemodialysis, requiring specialist dialysis nursing staff, is limited or may be delayed.

Serum Theophylline Level as Predictor for Complications in Adults with Acute Theophylline Overdose

“…In addition to an increased prevalence of use of certain medications with the potential for pharmacokinetic and pharmacodynamic interaction. Protein binding may be decreased by increasing the age resulting in an increased proportion of the serum theophylline concentration in the pharmacologically active unbound form (Fisher and Graudins, 2015).…”

“…Arrhythmia occurs in severe cases secondary to increased secretion of catecholamines (Hymel, 2016). Respiratory acidosis occurs due to CNS depression in severe toxicity (Fisher and Graudins, 2015).…”

“…Seizures are more common with acute overdose than with chronic overdose. In contrast, cardiac dysrhythmias are more common following a chronic overdose rather than acute overdose and with lower serum concentrations (Fisher and Graudins, 2015).…”

Dialysis and extracorporeal therapies for enhanced elimination of toxic ingestions and poisoning

“…Usual settings for a patient with acute renal insufficiency would be blood and dialysate flows of 200 ml/min with a substitution fluid rate of 100 ml/min. There are case reports of its use in various toxicities, involving similar flow rate parameters, however, trial data are lacking [95][96][97][98]. SLED likely achieves outcomes which balance the advantages and disadvantages of intermittent and continuous modalities, similar to its place in the management spectrum for kidney failure.…”

EDTA salt modified carbon paste electrode for square wave voltammetric determination of theophylline in pharmaceutical tablet formulation

“…Theophylline (TP), which is effective in the treatment of respiratory diseases is prescribed in the therapy of asthma and chronic obstructive pulmonary disorder in adults [2]. Moreover, TP is mainly used to treat emphysema, bronchial asthma, cardiac difficulty breathing, bronchitis, chronic obstructive pulmonary disease (COPD), apnea, and bradycardia [3].…”