Severe theophylline intoxication: a delay in charcoal haemoperfusion solved by oral activated charcoal

Email: j.rutten{at}erasmusmc.nl

Sir,

During the 1980s, clinicians worldwide were more frequently confronted with patients experiencing the effects of a theophylline intoxication than nowadays. However, while theophylline is still on the market, intoxications of theophylline can occur in chronic users as well as in acute overdoses [1]. The haemodynamic and neurological side effects in particular can result in significant morbidity and mortality [2]. Haemoperfusion with a charcoal filter is an established and efficient technique for removal of theophylline [3]. However, oral activated charcoal can also be very effective in lowering serum levels of theophylline, as we experienced while treating a patient with an overdose.

Case. A 22-year-old female was brought to the Emergency Department 6 h after ingestion of 20 g of sustained-release theophylline in a suicide attempt. She had not used theophylline before. The patient complained of nausea and experienced palpitations. Further medical history was insignificant. Laboratory investigation revealed a hypokalaemia (2.4 mmol/l) and a theophylline serum level of 105 mg/l.

After admission to the intensive care unit, she was sedated, intubated and mechanically ventilated in order to administer charcoal by gastric tube as severe nausea and vomiting were unresponsive to anti-emetics. The charcoal was given in three doses, in a total dose of 150 g. To accelerate enteral passage, magnesium sulfate was given by nasogastric tube until charcoal was seen in the stool 2 h later. One hour after admission, the patient experienced severe hypotension and possible epileptic activity, treated with colloids, inotropes and pentobarbital, respectively.

Due to technical difficulties, there was a significant delay of 6.5 h in the start of haemoperfusion since the first measured theophylline serum level. During this time, the patient received only oral activated charcoal and the serum theophylline level dropped from 105 to 48 mg/l. Additional clearance by haemoperfusion induced a drop to 24 mg/l; at that time, haemoperfusion was stopped. The following day, sedatives were stopped and the endotracheal tube removed; she made a full recovery.

Discussion. Oral activated charcoal is a well-established therapy for treatment of theophylline intoxication [4]. The effects of ingested charcoal are multiple: in addition to decreasing gut absorption, the ingested charcoal results in transluminal drug clearance from the systemic circulation [4,5]. The only contra-indications for the use of oral activated charcoal are ileus or co-ingestion of caustics. Magnesium sulfate was given because cathartics can reduce the risk of bowel obstruction [5]. Cathartics also decrease the transit time of charcoal, thereby preventing reabsorption of theophylline. Intractable vomiting is one of the major reasons for failure of oral activated charcoal therapy. Besides respiratory failure, intractable vomiting can in itself be an indication for sedation and ventilatory support. In this case, oral activated charcoal was a very effective way to remove theophylline, resulting in a >50% reduction in the theophylline serum level.

Conflict of interest statement. None declared.

Joost Rutten1, Bart van den Berg1, Teun van Gelder2 and Jan van Saase3

1 Department of Intensive Care2 Department of Clinical Pharmacology3 Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands

References

  1. Weinberger M, Hendeles L. Theophylline in asthma. N Engl J Med 1996; 334: 1380–1388[Free Full Text]
  2. Shannon M. Life threatening events after theophylline overdose, a 10-year prospective analysis. Arch Intern Med 1999; 159: 989–994[Abstract/Free Full Text]
  3. Gaudreault P, Guay J. Theophylline poisoning, pharmacological considerations and clinical management. Med Toxicol 1986; 1: 169–191[ISI]
  4. Cooling DS. Theophylline toxicity. J Emerg Med 1993; 11: 415–425[CrossRef][Medline]
  5. Shannon M. Predictors of major toxicity after theophylline overdose. Ann Intern Med 1993; 119: 1161–1167[Abstract/Free Full Text]




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