Euphyllin

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Euphyllin uses

Euphyllin consists of Aminophylline Hydrate, Theophylline.

Aminophylline Hydrate:



Euphyllin (Aminophylline Hydrate)

Injection, USP

25 mg/mL Euphyllin (Aminophylline Hydrate), Dihydrate

(Equivalent to 19.7 mg/mL of Anhydrous Theophylline)

Ampul

Fliptop Vial Rx only

DESCRIPTION

Euphyllin (Aminophylline Hydrate) Injection, USP is a sterile, nonpyrogenic solution of Euphyllin (Aminophylline Hydrate) in water for injection. Euphyllin (Aminophylline Hydrate) (dihydrate) is approximately 79% of anhydrous theophylline by weight. Euphyllin (Aminophylline Hydrate) Injection is administered by slow intravenous injection or diluted and administered by intravenous infusion.

The solution contains no bacteriostat or antimicrobial agent and is intended for use only as a single-dose injection. When smaller doses are required the unused portion should be discarded.

Euphyllin (Aminophylline Hydrate) is a 2:1 complex of theophylline and ethylenediamine. Theophylline is structurally classified as a methylxanthine. Euphyllin (Aminophylline Hydrate) occurs as a white or slightly yellowish granule or powder, with a slight ammoniacal odor. Euphyllin (Aminophylline Hydrate) has the chemical name 1H-Purine-2, 6-dione, 3,7-dihydro-1,3-dimethyl-, compound with 1,2-ethanediamine (2:1). The structural formula of Euphyllin (Aminophylline Hydrate) (dihydrate) is as follows:

The molecular formula of Euphyllin (Aminophylline Hydrate) dihydrate is C16H24N10O4 - 2(H2O) with a molecular weight of 456.46.

Euphyllin (Aminophylline Hydrate) Injection, USP contains Euphyllin (Aminophylline Hydrate) (calculated as the dihydrate) 25 mg/mL (equivalent to 19.7 mg/mL anhydrous theophylline) prepared with the aid of ethylenediamine. The solution may contain an excess of ethylenediamine for pH adjustment. pH is 8.8 (8.6 to 9.0). The osmolar concentration is 0.17 mOsmol/mL (calc.).

structural formula Euphyllin (Aminophylline Hydrate)

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CLINICAL PHARMACOLOGY

Mechanism of Action:

Theophylline has two distinct actions in the airways of patients with reversible obstruction; smooth muscle relaxation and suppression of the response of the airways to stimuli (i.e., nonbronchodilator prophylactic effects). While the mechanisms of action of theophylline are not known with certainty, studies in animals suggest that bronchodilation is mediated by the inhibition of two isozymes of phosphodiesterase (PDE III and, to a lesser extent, PDE IV), while nonbronchodilator prophylactic actions are probably mediated through one or more different molecular mechanisms, that do not involve inhibition of PDE III or antagonism of adenosine receptors. Some of the adverse effects associated with theophylline appear to be mediated by inhibition of PDE III (e.g., hypotension, tachycardia, headache, and emesis) and adenosine receptor antagonism (e.g., alterations in cerebral blood flow).

Theophylline increases the force of contraction of diaphragmatic muscles. This action appears to be due to enhancement of calcium uptake through an adenosine-mediated channel.

Serum Concentration-Effect Relationship:

Bronchodilation occurs over the serum theophylline concentration range of 5 - 20 mcg/mL. Clinically important improvement in symptom control and pulmonary function has been found in most studies to require serum theophylline concentrations >10 mcg/mL. At serum theophylline concentrations >20 mcg/mL, both the frequency and severity of adverse reactions increase. In general, maintaining the average serum theophylline concentration between 10 and 15 mcg/mL will achieve most of the drug's potential therapeutic benefit while minimizing the risk of serious adverse events.

Pharmacokinetics:

Overview The pharmacokinetics of theophylline vary widely among similar patients and cannot be predicted by age, sex, body weight or other demographic characteristics. In addition, certain concurrent illnesses and alterations in normal physiology (see Table I ) and co-administration of other drugs (see Table II ) can significantly alter the pharmacokinetic characteristics of theophylline. Within-subject variability in metabolism has also been reported in some studies, especially in acutely ill patients.

It is, therefore, recommended that serum theophylline concentrations be measured frequently in acutely ill patients receiving intravenous theophylline (e.g., at 24-hr. intervals). More frequent measurements should be made during the initiation of therapy and in the presence of any condition that may significantly alter theophylline clearance (see PRECAUTIONS , Effects on Laboratory Tests ).

¶ For various North American patient populations from literature reports. Different rates of elimination and consequent dosage requirements have been observed among other peoples.

* Clearance represents the volume of blood completely cleared of theophylline by the liver in one minute. Values listed were generally determined at serum theophylline concentrations, <20 mcg/mL; clearance may decrease and half-life may increase at higher serum concentrations due to nonlinear pharmacokinetics.

†† Reported range or estimated range (mean ± 2 SD) where actual range not reported.

NR = not reported or not reported in a comparable format.

** Median




Population Characteristics

Age


Total Body Clearance*

Mean (Range)††

(mL/kg/min)


Half-Life

Mean (Range)††

(hr)


Premature neonates

postnatal age 3 - 15 days

postnatal age 25 - 57 days



0.29 (0.09 - 0.49)

0.64 (0.04 - 1.2)



30 (17 - 43)

20 (9.4 - 30.6)


Term infants

postnatal age 1 - 2 days

postnatal age 3 - 30 weeks



NR

NR



25.7 (25 - 26.5)

11 (6 - 29)


Children

1 - 4 years

4 - 12 years

13 - 15 years

6 - 17 years



1.7 (0.5 - 2.9)

1.6 (0.8 - 2.4)

0.9 (0.48 - 1.3)

1.4 (0.2 - 2.6)



3.4 (1.2 - 5.6)

NR

NR

3.7 (1.5 - 5.9)


Adults (16 - 60 years)

otherwise healthy

nonsmoking asthmatics




0.65 (0.27 - 1.03)




8.7 (6.1 - 12.8)


Elderly (>60 years)

nonsmokers with normal cardiac,

liver, and renal function




0.41 (0.21 - 0.61)




9.8 (1.6 - 18)


Concurrent Illness Or Altered Physiological State


Acute pulmonary edema


0.33** (0.07 - 2.45)


19** (3.1 - 8.2)


COPD- >60 years, stable

nonsmoker >1 year



0.54 (0.44 - 0.64)



11 (9.4 - 12.6)


COPD with cor pulmonale


0.48 (0.08 - 0.88)


NR


Cystic fibrosis (14 - 28 years)


1.25 (0.31 - 2.2)


6 (1.8 - 10.2)


Fever associated with acute viral respiratory


illness (children 9 - 15 years)


NR


7 (1.0 - 13)


Liver disease – cirrhosis

acute hepatitis

cholestasis


0.31** (0.1 - 0.7)

0.35 (0.25 - 0.45)

0.65 (0.25 - 1.45)


32** (10 - 56)

19.2 (16.6 - 21.8)

14.4 (5.7 - 31.8)


Pregnancy – 1st trimester

2nd trimester

3rd trimester


NR

NR

NR


8.5 (3.1 - 13.9)

8.8 (3.8 - 13.8)

13 (8.4 - 17.6)


Sepsis with multi-organ failure


0.47 (0.19 - 1.9)


18.8 (6.3 - 24.1)


Thyroid disease – hypothyroid

hyperthyroid


0.38 (0.13 - 0.57)

0.8 (0.68 - 0.97)


11.6 (8.2 - 25)

4.5 (3.7 - 5.6)


Note: In addition to the factors listed above, theophylline clearance is increased and half-life decreased by low carbohydrate/high protein diets, parenteral nutrition, and daily consumption of charcoal-broiled beef. A high carbohydrate/low protein diet can decrease the clearance and prolong the half-life of theophylline.

Distribution Once theophylline enters the systemic circulation, about 40% is bound to plasma protein, primarily albumin. Unbound theophylline distributes throughout body water, but distributes poorly into body fat. The apparent volume of distribution of theophylline is approximately 0.45 L/kg (range 0.3 - 0.7 L/kg) based on ideal body weight. Theophylline passes freely across the placenta, into breast milk and into the cerebrospinal fluid (CSF). Saliva theophylline concentrations approximate unbound serum concentrations, but are not reliable for routine or therapeutic monitoring unless special techniques are used. An increase in the volume of distribution of theophylline, primarily due to reduction in plasma protein binding, occurs in premature neonates, patients with hepatic cirrhosis, uncorrected acidemia, the elderly and in women during the third trimester of pregnancy. In such cases, the patient may show signs of toxicity at total (bound + unbound) serum concentrations of theophylline in the therapeutic range (10 - 20 mcg/mL) due to elevated concentrations of the pharmacologically active unbound drug. Similarly, a patient with decreased theophylline binding may have a sub-therapeutic total drug concentration while the pharmacologically active unbound concentration is in the therapeutic range. If only total serum theophylline concentration is measured, this may lead to an unnecessary and potentially dangerous dose increase. In patients with reduced protein binding, measurement of unbound serum theophylline concentration provides a more reliable means of dosage adjustment than measurement of total serum theophylline concentration. Generally, concentrations of unbound theophylline should be maintained in the range of 6 - 12 mcg/mL.

Metabolism In adults and children beyond one year of age, approximately 90% of the dose is metabolized in the liver. Biotransformation takes place through demethylation to 1-methylxanthine and 3-methylxanthine and hydroxylation to 1,3-dimethyluric acid. 1-methylxanthine is further hydroxylated, by xanthine oxidase, to 1-methyluric acid. About 6% of a theophylline dose is N-methylated to caffeine. Theophylline demethylation to 3-methylxanthine is catalyzed by cytochrome P-450 1A2, while cytochromes P-450 2E1 and P-450 3A3 catalyze the hydroxylation to 1,3-dimethyluric acid. Demethylation to 1-methylxanthine appears to be catalyzed either by cytochrome P-450 1A2 or a closely related cytochrome. In neonates, the N-demethylation pathway is absent while the function of the hydroxylation pathway is markedly deficient. The activity of these pathways slowly increases to maximal levels by one year of age.

Caffeine and 3-methylxanthine are the only theophylline metabolites with pharmacologic activity. 3-methylxanthine has approximately one tenth the pharmacologic activity of theophylline and serum concentrations in adults with normal renal function are <1 mcg/mL. In patients with end-stage renal disease, 3-methylxanthine may accumulate to concentrations that approximate the unmetabolized theophylline concentration. Caffeine concentrations are usually undetectable in adults regardless of renal function. In neonates, caffeine may accumulate to concentrations that approximate the unmetabolized theophylline concentration and thus, exert a pharmacologic effect.

Both the N-demethylation and hydroxylation pathways of theophylline biotransformation are capacity-limited. Due to the wide intersubject variability of the rate of theophylline metabolism, nonlinearity of elimination may begin in some patients at serum theophylline concentrations <10 mcg/mL. Since this nonlinearity results in more than proportional changes in serum theophylline concentrations with changes in dose, it is advisable to make increases or decreases in dose in small increments in order to achieve desired changes in serum theophylline concentrations (See DOSAGE AND ADMINISTRATION , Table VI ). Accurate prediction of dose-dependency of theophylline metabolism in patients a priori is not possible, but patients with very high initial clearance rates (i.e., low steady state serum theophylline concentrations at above average doses) have the greatest likelihood of experiencing large changes in serum theophylline concentration in response to dosage changes.

Excretion In neonates, approximately 50% of the theophylline dose is excreted unchanged in the urine. Beyond the first three months of life, approximately 10% of the theophylline dose is excreted unchanged in the urine. The remainder is excreted in the urine mainly as 1,3-dimethyluric acid (35 - 40%), 1-methyluric acid (20 - 25%) and 3-methylxanthine (15 - 20%). Since little theophylline is excreted unchanged in the urine and since active metabolites of theophylline (i.e., caffeine, 3-methylxanthine) do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, the large fraction of the theophylline dose excreted in the urine as unchanged theophylline and caffeine in neonates requires careful attention to dose reduction and frequent monitoring of serum theophylline concentrations in neonates with reduced renal function (see WARNINGS ).

Serum Concentrations at Steady State In a patient who has received no theophylline in the previous 24 hours, a loading dose of intravenous theophylline of 4.6 mg/kg (5.7 mg/kg as Euphyllin (Aminophylline Hydrate)), calculated on the basis of ideal body weight and administered over 30 minutes, on average, will produce a maximum post-distribution serum concentration of 10 mcg/mL with a range of 6-16 mcg/mL. In non-smoking adults, initiation of a constant intravenous theophylline infusion of 0.4 mg/kg/hr (0.5 mg/kg/hr as Euphyllin (Aminophylline Hydrate)) at the completion of the loading dose, on average, will result in a steady-state concentration of 10 mcg/mL with a range of 7-26 mcg/mL. The mean and range of steady-state serum concentrations are similar when the average child (age 1 to 9 years) is given a loading dose of 4.6 mg/kg theophylline (5.7 mg/kg as Euphyllin (Aminophylline Hydrate)) followed by a constant intravenous infusion of 0.8 mg/kg/hr (1.0 mg/kg/hr as Euphyllin (Aminophylline Hydrate)). (See DOSAGE AND ADMINISTRATION .)

Special Populations (See Table I for mean clearance and half-life values)

Geriatric The clearance of theophylline is decreased by an average of 30% in healthy elderly adults (>60 yrs.) compared to healthy young adults. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in elderly patients (see WARNINGS ).

Pediatrics The clearance of theophylline is very low in neonates (see WARNINGS ). Theophylline clearance reaches maximal values by one year of age, remains relatively constant until about 9 years of age and then slowly decreases by approximately 50% to adult values at about age 16. Renal excretion of unchanged theophylline in neonates amounts to about 50% of the dose, compared to about 10% in children older than three months and in adults. Careful attention to dosage selection and monitoring of serum theophylline concentrations are required in children (see WARNINGS and DOSAGE AND ADMINISTRATION ).

Gender Gender differences in theophylline clearance are relatively small and unlikely to be of clinical significance. Significant reduction in theophylline clearance, however, has been reported in women on the 20th day of the menstrual cycle and during the third trimester of pregnancy.

Race Pharmacokinetic differences in theophylline clearance due to race have not been studied.

Renal Insufficiency Only a small fraction, e.g., about 10%, of the administered theophylline dose is excreted unchanged in the urine of children greater than three months of age and adults. Since little theophylline is excreted unchanged in the urine and since active metabolites of theophylline (i.e., caffeine, 3-methylxanthine) do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, approximately 50% of the administered theophylline dose is excreted unchanged in the urine in neonates. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in neonates with decreased renal function (see WARNINGS ).

Hepatic Insufficiency Theophylline clearance is decreased by 50% or more in patients with hepatic insufficiency (e.g., cirrhosis, acute hepatitis, cholestasis). Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in patients with reduced hepatic function (see WARNINGS ).

Congestive Heart Failure (CHF) Theophylline clearance is decreased by 50% or more in patients with CHF. The extent of reduction in theophylline clearance in patients with CHF appears to be directly correlated to the severity of the cardiac disease. Since theophylline clearance is independent of liver blood flow, the reduction in clearance appears to be due to impaired hepatocyte function rather than reduced perfusion. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in patients with CHF (see WARNINGS ).

Smokers Tobacco and marijuana smoking appears to increase the clearance of theophylline by induction of metabolic pathways. Theophylline clearance has been shown to increase by approximately 50% in young adult tobacco smokers and by approximately 80% in elderly tobacco smokers compared to nonsmoking subjects. Passive smoke exposure has also been shown to increase theophylline clearance by up to 50%. Abstinence from tobacco smoking for one week causes a reduction of approximately 40% in theophylline clearance. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in patients who stop smoking (see WARNINGS ). Use of nicotine gum has been shown to have no effect on theophylline clearance.

Fever Fever, regardless of its underlying cause, can decrease the clearance of theophylline. The magnitude and duration of the fever appear to be directly correlated to the degree of decrease of theophylline clearance. Precise data are lacking, but a temperature of 39°C (102°F) for at least 24 hours is probably required to produce a clinically significant increase in serum theophylline concentrations. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in patients with sustained fever (see WARNINGS ).

Miscellaneous Other factors associated with decreased theophylline clearance include the third trimester of pregnancy, sepsis with multiple organ failure, and hypothyroidism. Careful attention to dose reduction and frequent monitoring of serum theophylline concentrations are required in patients with any of these conditions (see WARNINGS ). Other factors associated with increased theophylline clearance include hyperthyroidism and cystic fibrosis.

Clinical Studies:

Inhaled beta-2 selective agonists and systemically administered corticosteroids are the treatments of first choice for management of acute exacerbations of asthma. The results of controlled clinical trials on the efficacy of adding intravenous theophylline to inhaled beta-2 selective agonists and systemically administered corticosteroids in the management of acute exacerbations of asthma have been conflicting. Most studies in patients treated for acute asthma exacerbations in an emergency department have shown that addition of intravenous theophylline does not produce greater bronchodilation and increases the risk of adverse effects. In contrast, other studies have shown that addition of intravenous theophylline is beneficial in the treatment of acute asthma exacerbations in patients requiring hospitalization, particularly in patients who are not responding adequately to inhaled beta-2 selective agonists.

In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that theophylline decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements.

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INDICATIONS AND USAGE

Intravenous theophylline is indicated as an adjunct to inhaled beta-2 selective agonists and systemically administered corticosteroids for the treatment of acute exacerbations of the symptoms and reversible airflow obstruction associated with asthma and other chronic lung diseases, e.g., emphysema and chronic bronchitis.

CONTRAINDICATIONS

Euphyllin (Aminophylline Hydrate) is contraindicated in patients with a history of hypersensitivity to theophylline or other components in the product including ethylenediamine.

WARNINGS

Concurrent Illness:

Theophylline should be used with extreme caution in patients with the following clinical conditions due to the increased risk of exacerbation of the concurrent condition:

Active peptic ulcer disease

Seizure disorders

Cardiac arrhythmias

Conditions That Reduce Theophylline Clearance:

There are several readily identifiable causes of reduced theophylline clearance. If the infusion rate is not appropriately reduced in the presence of these risk factors, severe and potentially fatal theophylline toxicity can occur. Careful consideration must be given to the benefits and risks of theophylline use and the need for more intensive monitoring of serum theophylline concentrations in patients with the following risk factors:

Age

Neonates (term and premature)

Children <1 year

Elderly (>60 years)

Concurrent Diseases

Acute pulmonary edema

Congestive heart failure

Cor pulmonale

Fever; ≥102° for 24 hours or more; or lesser temperature

elevations for longer periods

Hypothyroidism

Liver disease; cirrhosis, acute hepatitis

Reduced renal function in infants <3 months of age

Sepsis with multi-organ failure

Shock

Cessation of Smoking

Drug Interactions

Adding a drug that inhibits theophylline metabolism (e.g., cimetidine, erythromycin, tacrine) or stopping a concurrently administered drug that enhances theophylline metabolism (e.g., carbamazepine, rifampin). (See PRECAUTIONS , Drug Interactions, Table II .)

When Signs or Symptoms of Theophylline Toxicity Are Present:

Whenever a patient receiving theophylline develops nausea or vomiting, particularly repetitive vomiting, or other signs or symptoms consistent with theophylline toxicity (even if another cause may be suspected), the intravenous infusion should be stopped and a serum theophylline concentration measured immediately.

Dosage Increases

Increases in the dose of intravenous theophylline should not be made in response to an acute exacerbation of symptoms unless the steady-state serum theophylline concentration is <10 mcg/mL.

As the rate of theophylline clearance may be dose-dependent (i.e., steady-state serum concentrations may increase disproportionately to the increase in dose), an increase in dose based upon a sub-therapeutic serum concentration measurement should be conservative. In general, limiting infusion rate increases to about 25% of the previous infusion rate will reduce the risk of unintended excessive increases in serum theophylline concentration (see DOSAGE AND ADMINISTRATION , TABLE VI ).

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PRECAUTIONS

General

Careful consideration of the various interacting drugs and physiologic conditions that can alter theophylline clearance and require dosage adjustment should occur prior to initiation of theophylline therapy and prior to increases in theophylline dose.

Monitoring Serum Theophylline Concentrations:

Serum theophylline concentration measurements are readily available and should be used to determine whether the dosage is appropriate. Specifically, the serum theophylline concentration should be measured as follows:

  • Before making a dose increase to determine whether the serum concentration is sub-therapeutic in a patient who continues to be symptomatic.
  • Whenever signs or symptoms of theophylline toxicity are present.
  • Whenever there is a new illness, worsening of an existing concurrent illness or a change in the patient's treatment regimen that may alter theophylline clearance (e.g., fever >102°F sustained for ≥24 hours, hepatitis, or drugs listed in Table II are added or discontinued).

In patients who have received no theophylline in the previous 24 hours, a serum concentration should be measured 30 minutes after completion of the intravenous loading dose to determine whether the serum concentration is <10 mcg/mL indicating the need for an additional loading dose or >20 mcg/mL indicating the need to delay starting the constant I.V. infusion. Once the infusion is begun, a second measurement should be obtained after one expected half-life (e.g., approximately 4 hours in children 1 to 9 years and 8 hours in non-smoking adults; See Table I for the expected half-life in additional patient populations). The second measurement should be compared to the first to determine the direction in which the serum concentration has changed. The infusion rate can then be adjusted before steady state is reached in an attempt to prevent an excessive or sub-therapeutic theophylline concentration from being achieved.

If a patient has received theophylline in the previous 24 hours, the serum concentration should be measured before administering an intravenous loading dose to make sure that it is safe to do so. If a loading dose is not indicated (i.e., the serum theophylline concentration is ≥10 mcg/mL), a second measurement should be obtained as above at the appropriate time after starting the intravenous infusion. If, on the other hand, a loading dose is indicated (See DOSAGE AND ADMINISTRATION for guidance on selection of the appropriate loading dose), a second blood sample should be obtained after the loading dose and a third sample should be obtained one expected half-life after starting the constant infusion to determine the direction in which the serum concentration has changed.

Once the above procedures related to initiation of intravenous theophylline infusion have been completed, subsequent serum samples for determination of theophylline concentration should be obtained at 24-hour intervals for the duration of the infusion. The theophylline infusion rate should be increased or decreased as appropriate based on the serum theophylline levels.

When signs or symptoms of theophylline toxicity are present, the intravenous infusion should be stopped and a serum sample for theophylline concentration should be obtained as soon as possible, analyzed immediately, and the result reported to the clinician without delay. In patients in whom decreased serum protein binding is suspected (e.g., cirrhosis, women during the third trimester of pregnancy), the concentration of unbound theophylline should be measured and the dosage adjusted to achieve an unbound concentration of 6-12 mcg/mL.

Saliva concentrations of theophylline cannot be used reliably to adjust dosage without special techniques.

Effects on Laboratory Tests:

As a result of its pharmacological effects, theophylline at serum concentrations within the 10 - 20 mcg/mL range modestly increases plasma glucose (from a mean of 88 mg% to 98 mg%), uric acid (from a mean of 4 mg/dl to 6 mg/dl), free fatty acids (from a mean of 451 µEq/L to 800 µEq/L), total cholesterol (from a mean of 140 vs 160 mg/dl), HDL (from a mean of 36 to 50 mg/dl), HDL/LDL ratio (from a mean of 0.5 to 0.7), and urinary free cortisol excretion (from a mean of 44 to 63 mcg/24 hr). Theophylline at serum concentrations within the 10 - 20 mcg/mL range may also transiently decrease serum concentrations of triiodothyronine (144 before, 131 after one week and 142 ng/dl after 4 weeks of theophylline). The clinical importance of these changes should be weighed against the potential therapeutic benefit of theophylline in individual patients.

Drug Interactions:

Theophylline interacts with a wide variety of drugs. The interaction may be pharmacodynamic, i.e., alterations in the therapeutic response to theophylline or another drug or occurrence of adverse effects without a change in serum theophylline concentration. More frequently, however, the interaction is pharmacokinetic, i.e., the rate of theophylline clearance is altered by another drug resulting in increased or decreased serum theophylline concentrations. Theophylline only rarely alters the pharmacokinetics of other drugs.

The drugs listed in Table II have the potential to produce clinically significant pharmacodynamic or pharmacokinetic interactions with theophylline. The information in the "Effect" column of Table II assumes that the interacting drug is being added to a steady-state theophylline regimen. If theophylline is being initiated in a patient who is already taking a drug that inhibits theophylline clearance, the dose of theophylline required to achieve a therapeutic serum theophylline concentration will be smaller. Conversely, if theophylline is being initiated in a patient who is already taking a drug that enhances theophylline clearance (e.g., rifampin), the dose of theophylline required to achieve a therapeutic serum theophylline concentration will be larger. Discontinuation of a concomitant drug that increases theophylline clearance will result in accumulation of theophylline to potentially toxic levels, unless the theophylline dose is appropriately reduced. Discontinuation of a concomitant drug that inhibits theophylline clearance will result in decreased serum theophylline concentrations, unless the theophylline dose is appropriately increased.

The drugs listed in Table III have either been documented not to interact with theophylline or do not produce a clinically significant interaction (i.e., <15% change in theophylline clearance).

The listing of drugs in Tables II and III are current as of September 1, 1995. New interactions are continuously being reported for theophylline, especially with new chemical entities. The clinician should not assume that a drug does not interact with theophylline if it is not listed in Table II . Before addition of a newly available drug in a patient receiving theophylline, the package insert of the new drug and/or the medical literature should be consulted to determine if an interaction between the new drug and theophylline has been reported.

Drug Type Of Interaction Effect**
* Refer to PRECAUTIONS , Drug Interactions for further information regarding table.

** Average effect on steady-state theophylline concentration or other clinical effect for pharmacologic interactions. Individual patients may experience larger changes in serum theophylline concentration than the value listed.


Adenosine


Theophylline blocks adenosine receptors.


Higher doses of adenosine may be required to achieve desired effect.


Alcohol


A single large dose of alcohol (3 mL/kg of whiskey) decreases theophylline clearance for up to 24 hours.


30% increase


Allopurinol


Decreases theophylline clearance at allopurinol doses ≥600 mg/day.


25% increase


Aminoglutethimide


Increases theophylline clearance by induction of microsomal enzyme activity.


25% decrease


Carbamazepine


Similar to aminoglutethimide.


30% decrease


Cimetidine


Decreases theophylline clearance by inhibiting cytochrome P450 1A2.


70% increase


Ciprofloxacin


Similar to cimetidine.


40% increase


Clarithromycin


Similar to erythromycin.


25% increase


Diazepam


Benzodiazepines increase CNS concentrations of adenosine, a potent CNS depressant, while theophylline blocks adenosine receptors.


Larger diazepam doses may be required to produce desired level of sedation. Discontinuation of theophylline without reduction of diazepam dose may result in respiratory depression.


Disulfiram


Decreases theophylline clearance by inhibiting hydroxylation and demethylation.


50% increase


Enoxacin


Similar to cimetidine.


300% increase


Ephedrine


Synergistic CNS effects.


Increased frequency of nausea, nervousness, and insomnia.


Erythromycin


Erythromycin metabolite decreases theophylline clearance by inhibiting

cytochrome P450 3A3.


35% increase. Erythromycin steady-state serum concentrations decrease by a similar amount.


Estrogen


Estrogen containing oral contraceptives decrease theophylline clearance in a dose-dependent fashion.

The effect of progesterone on theophylline clearance is unknown.


30% increase


Flurazepam


Similar to diazepam.


Similar to diazepam.


Fluvoxamine


Similar to cimetidine.


Similar to cimetidine.


Halothane


Halothane sensitizes the myocardium to catecholamines, theophylline increases release of endogenous catecholamines.


Increased risk of ventricular arrhythmias.


Interferon, human recombinant alpha-A


Decreases theophylline clearance.


100% increase


Isoproterenol (I.V.)


Increases theophylline clearance.


20% decrease


Ketamine


Pharmacologic


May lower theophylline seizure threshold.


Lithium


Theophylline increases renal lithium clearance.


Lithium dose required to achieve a therapeutic serum concentration increased an average of 60%.


Lorazepam


Similar to diazepam.


Similar to diazepam.


Methotrexate (MTX)


Decreases theophylline clearance.


20% increase after low dose MTX, higher dose MTX may have a greater effect.


Mexiletine


Similar to disulfiram.


80% increase


Midazolam


Similar to diazepam.


Similar to diazepam.


Moricizine


Increases theophylline clearance.


25% decrease


Pancuronium


Theophylline may antagonize nondepolarizing neuromuscular blocking effects; possibly due to phosphodiesterase inhibition.


Larger dose of pancuronium may be required to achieve neuromuscular blockade.


Pentoxifylline


Decreases theophylline clearance.


30% increase


Phenobarbital (PB)


Similar to aminoglutethimide.


25% decrease after two weeks of concurrent Phenobarbital.


Phenytoin


Phenytoin increases theophylline clearance by increasing microsomal enzyme activity. Theophylline decreases phenytoin absorption.


Serum theophylline and phenytoin concentrations decrease about 40%.


Propafenone


Decreases theophylline clearance and pharmacologic interaction.


40% increase. Beta-2 blocking effect may decrease efficacy of theophylline.


Propranolol


Similar to cimetidine and pharmacologic interaction.


100% increase. Beta-2 blocking effect may decrease efficacy of theophylline.


Rifampin


Increases theophylline clearance by increasing cytochrome P450 1A2 and 3A3 activity.


20 - 40% decrease


Sulfinpyrazone


Increases theophylline clearance by increasing demethylation and hydroxylation. Decreases renal clearance of theophylline.


20% decrease


Tacrine


Similar to cimetidine, also increases renal clearance of theophylline.


90% increase


Thiabendazole


Decreases theophylline clearance.


190% increase


Ticlopidine


Decreases theophylline clearance.


60% increase


Troleandomycin


Similar to erythromycin.


33 - 100% increase depending on troleandomycin dose.


Verapamil


Similar to disulfiram.


20% increase


albuterol,

systemic and inhaled

amoxicillin

ampicillin,

with or without sulbactam

atenolol

azithromycin

caffeine,

dietary ingestion

cefaclor

co-trimoxazole

(trimethoprim and sulfamethoxazole)

diltiazem

dirithromycin

enflurane

famotidine

felodipine

finasteride

hydrocortisone

isoflurane

isoniazid

isradipine

influenza vaccine

ketoconazole


lomefloxacin

mebendazole

medroxyprogesterone

methylprednisolone

metronidazole

metoprolol

nadolol

nifedipine

nizatidine

norfloxacin

ofloxacin

omeprazole

prednisone, prednisolone

ranitidine

rifabutin

roxithromycin

sorbitol

(purgative doses do not inhibit

theophylline absorption)

sucralfate

terbutaline, systemic

terfenadine

tetracycline

tocainide


The Effect of Other Drugs on Theophylline Serum Concentration Measurements:

Most serum theophylline assays in clinical use are immunoassays which are specific for theophylline. Other xanthines such as caffeine, dyphylline, and pentoxifylline are not detected by these assays. Some drugs (e.g., cefazolin, cephalothin), however, may interfere with certain HPLC techniques. Caffeine and xanthine metabolites in neonates or patients with renal dysfunction may cause the reading from some dry reagent office methods to be higher than the actual serum theophylline concentration.

Carcinogenesis, Mutagenesis, and Impairment of Fertility:

Long term carcinogenicity studies have been carried out in mice (oral doses 30 - 150 mg/kg) and rats (oral doses 5 - 75 mg/kg). Results are pending.

Theophylline has been studied in Ames salmonella, in vivo and in vitro cytogenetics, micronucleus and Chinese hamster ovary test systems and has not been shown to be genotoxic.

In a 14 week continuous breeding study, theophylline, administered to mating pairs of B6C3F1 mice at oral doses of 120, 270 and 500 mg/kg (approximately 1.0 - 3.0 times the human dose on a mg/m2 basis) impaired fertility, as evidenced by decreases in the number of live pups per litter, decreases in the mean number of litters per fertile pair, and increases in the gestation period at the high dose as well as decreases in the proportion of pups born alive at the mid and high dose. In 13 week toxicity studies, theophylline was administered to F344 rats and B6C3F1 mice at oral doses of 40 - 300 mg/kg (approximately 2 times the human dose on a mg/m2 basis). At the high dose, systemic toxicity was observed in both species including decreases in testicular weight.

Pregnancy:

Category C: There are no adequate and well controlled studies in pregnant women. Additionally, there are no teratogenicity studies in nonrodents. Theophylline was not shown to be teratogenic in CD-1 mice at oral doses up to 400 mg/kg, approximately 2.0 times the human dose on a mg/m2 basis or in CD-1 rats at oral doses up to 260 mg/kg, approximately 3.0 times the recommended human dose on a mg/m2 basis. At a dose of 220 mg/kg, embryotoxicity was observed in rats in the absence of maternal toxicity.

Nursing Mothers:

Theophylline is excreted into breast milk and may cause irritability or other signs of mild toxicity in nursing human infants. The concentration of theophylline in breast milk is about equivalent to the maternal serum concentration. An infant ingesting a liter of breast milk containing 10 - 20 mcg/mL of theophylline per day is likely to receive 10 - 20 mg of theophylline per day. Serious adverse effects in the infant are unlikely unless the mother has toxic serum theophylline concentrations.

Pediatric Use:

Theophylline is safe and effective for the approved indications in pediatric patients. The constant infusion rate of intravenous theophylline must be selected with caution in pediatric patients since the rate of theophylline clearance is highly variable across the age range of neonates to adolescents (see CLINICAL PHARMACOLOGY , Table I , WARNINGS , and DOSAGE AND ADMINISTRATION , Table V ). Due to the immaturity of theophylline metabolic pathways in pediatric patients under the age of one year, particular attention to dosage selection and frequent monitoring of serum theophylline concentrations are required when theophylline is prescribed to pediatric patients in this age group.

Geriatric Use:

Elderly patients are at significantly greater risk of experiencing serious toxicity from theophylline than younger patients due to pharmacokinetic and pharmacodynamic changes associated with aging. Theophylline clearance is reduced in patients greater than 60 years of age, resulting in increased serum theophylline concentrations in response to a given theophylline infusion rate. Protein binding may be decreased in the elderly resulting in a larger proportion of the total serum theophylline concentration in the pharmacologically active unbound form. Elderly patients also appear to be more sensitive to the toxic effects of theophylline after chronic overdosage than younger patients. For these reasons, the maximum infusion rate of theophylline in patients greater than 60 years of age ordinarily should not exceed 17 mg/hr (21 mg/hr as Euphyllin (Aminophylline Hydrate)) unless the patient continues to be symptomatic and the peak steady state serum theophylline concentration is <10 mcg/mL (see DOSAGE AND ADMINISTRATION ). Theophylline infusion rates greater than 17 mg/hr (21 mg/hr as Euphyllin (Aminophylline Hydrate)) should be prescribed with caution in elderly patients.

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ADVERSE REACTIONS

Adverse reactions associated with theophylline are generally mild when peak serum theophylline concentrations are <20 mcg/mL and mainly consist of transient caffeine-like adverse effects such as nausea, vomiting, headache, and insomnia. When peak serum theophylline concentrations exceed 20 mcg/mL, however, theophylline produces a wide range of adverse reactions including persistent vomiting, cardiac arrhythmias, and intractable seizures which can be lethal (see OVERDOSAGE ).

Other adverse reactions that have been reported at serum theophylline concentrations <20 mcg/mL include diarrhea, irritability, restlessness, fine skeletal muscle tremors, and transient diuresis. In patients with hypoxia secondary to COPD, multifocal atrial tachycardia and flutter have been reported at serum theophylline concentrations ≥15 mcg/mL. There have been a few isolated reports of seizures at serum theophylline concentrations <20 mcg/mL in patients with an underlying neurological disease or in elderly patients. The occurrence of seizures in elderly patients with serum theophylline concentrations <20 mcg/mL may be secondary to decreased protein binding resulting in a larger proportion of the total serum theophylline concentration in the pharmacologically active unbound form. The clinical characteristics of the seizures reported in patients with serum theophylline concentrations <20 mcg/mL have generally been milder than seizures associated with excessive serum theophylline concentrations resulting from an overdose (i.e., they have generally been transient, often stopped without anticonvulsant therapy, and did not result in neurological residua).

Products containing Euphyllin (Aminophylline Hydrate) may rarely produce severe allergic reactions of the skin, including exfoliative dermatitis, after systemic administration in a patient who has been previously sensitized by topical application of a substance containing ethylenediamine. In such patients skin patch tests are positive for ethylenediamine, a component of Euphyllin (Aminophylline Hydrate), and negative for theophylline. Pharmacists and other individuals who experience repeated skin exposure while physically handling Euphyllin (Aminophylline Hydrate) may develop a contact dermatitis due to the ethylenediamine component.

* These data are derived from two studies in patients with serum theophylline concentrations

>30 mcg/mL. In the first study (Study #1 – Shanon, Ann Intern Med 1993;119:1161-67), data were prospectively collected from 249 consecutive cases of theophylline toxicity referred to a regional poison center for consultation. In the second study (Study #2 – Sessler, Am J Med 1990; 88:567-76), data were retrospectively collected from 116 cases with serum theophylline concentrations >30 mcg/mL among 6000 blood samples obtained for measurement of serum theophylline concentrations in three emergency departments. Differences in the incidence of manifestations of theophylline toxicity between the two studies may reflect sample selection as a result of study design (e.g., in Study #1, 48% of the patients had acute intoxications versus only 10% in Study #2) and different methods of reporting results.

** NR = Not reported in a comparable manner.


Acute Overdose

(Large Single Ingestion)


Chronic Overdosage

(Multiple Excessive Doses)


Sign/Symptom


Study 1

(n=157)


Study 2

(n=14)


Study 1

(n=92)


Study 2

(n=102)


Asymptomatic


NR**


0


NR**


6


Gastrointestinal


Vomiting


73


93


30


61


Abdominal pain


NR**


21


NR**


12


Diarrhea


NR**


0


NR**


14


Hematemesis


NR**


0


NR**


2


Metabolic/Other


Hypokalemia


85


79


44


43


Hyperglycemia


98


NR**


18


NR**


Acid/base disturbance


34


21


9


5


Rhabdomyolysis


NR**


7


NR**


0


Cardiovascular


Sinus tachycardia


100


86


100


62


Other supraventricular


2


21


12


14


tachycardias


Ventricular premature beats


3


21


10


19


Atrial fibrillation or flutter


1


NR**


12


NR**


Multifocal atrial tachycardia


0


NR**


2


NR**


Ventricular arrhythmias with


7


14


40


0


hemodynamic instability


Hypotension/shock


NR**


21


NR**


8


Neurologic


Nervousness


NR**


64


NR**


21


Tremors


38


29


16


14


Disorientation


NR**


7


NR**


11


Seizures


5


14


14


5


Death


3


21


10


4

OVERDOSAGE

General:

The chronicity and pattern of theophylline overdosage significantly influences clinical manifestations of toxicity, management and outcome. There are two common presentations: 1) acute overdose, i.e., infusion of an excessive loading dose or excessive maintenance infusion rate for less than 24 hours, and 2) chronic overdosage, i.e., excessive maintenance infusion rate for greater than 24 hours. The most common causes of chronic theophylline overdosage include clinician prescribing of an excessive dose or a normal dose in the presence of factors known to decrease the rate of theophylline clearance and increasing the dose in response to an exacerbation of symptoms without first measuring the serum theophylline concentration to determine whether a dose increase is safe.

Several studies have described the clinical manifestations of theophylline overdose following oral administration and attempted to determine the factors that predict life-threatening toxicity. In general, patients who experience an acute overdose are less likely to experience seizures than patients who have experienced a chronic overdosage, unless the peak serum theophylline concentration is >100 mcg/mL. After a chronic overdosage, generalized seizures, life-threatening cardiac arrhythmias, and death may occur at serum theophylline concentrations >30 mcg/mL. The severity of toxicity after chronic overdosage is more strongly correlated with the patient's age than the peak serum theophylline concentration; patients >60 years are at the greatest risk for severe toxicity and mortality after a chronic overdosage. Pre-existing or concurrent disease may also significantly increase the susceptibility of a patient to a particular toxic manifestation, e.g., patients with neurologic disorders have an increased risk of seizures and patients with cardiac disease have an increased risk of cardiac arrhythmias for a given serum theophylline concentration compared to patients without the underlying disease.

The frequency of various reported manifestations of oral theophylline overdose according to the mode of overdose are listed in Table IV .

Other manifestations of theophylline toxicity include increases in serum calcium, creatine kinase, myoglobin and leukocyte count, decreases in serum phosphate and magnesium, acute myocardial infarction, and urinary retention in men with obstructive uropathy.

Seizures associated with serum theophylline concentrations >30 mcg/mL are often resistant to anticonvulsant therapy and may result in irreversible brain injury if not rapidly controlled. Death from theophylline toxicity is most often secondary to cardiorespiratory arrest and/or hypoxic encephalopathy following prolonged generalized seizures or intractable cardiac arrhythmias causing hemodynamic compromise.

Overdose Management:

General Recommendations for Patients with Symptoms of Theophylline Overdose or Serum Theophylline Concentrations >30 mcg/mL While Receiving Intravenous Theophylline.

  • Stop the theophylline infusion.
  • While simultaneously instituting treatment, contact a regional poison center to obtain updated information and advice on individualizing the recommendations that follow.
  • Institute supportive care, including establishment of intravenous access, maintenance of the airway, and electrocardiographic monitoring.
  • Treatment of seizures Because of the high morbidity and mortality associated with theophylline-induced seizures, treatment should be rapid and aggressive. Anticonvulsant therapy should be initiated with an intravenous benzodiazepine, e.g., diazepam, in increments of 0.1 - 0.2 mg/kg every 1 - 3 minutes until seizures are terminated. Repetitive seizures should be treated with a loading dose of phenobarbital. Case reports of theophylline overdose in humans and animal studies suggest that phenytoin is ineffective in terminating theophylline-induced seizures. The doses of benzodiazepines and phenobarbital required to terminate theophylline-induced seizures are close to the doses that may cause severe respiratory depression or respiratory arrest; the clinician should therefore be prepared to provide assisted ventilation. Elderly patients and patients with COPD may be more susceptible to the respiratory depressant effects of anticonvulsants. Barbiturate-induced coma or administration of general anesthesia may be required to terminate repetitive seizures or status epilepticus. General anesthesia should be used with caution in patients with theophylline overdose because fluorinated volatile anesthetics may sensitize the myocardium to endogenous catecholamines released by theophylline. Enflurane appears less likely to be associated with this effect than halothane and may, therefore, be safer. Neuromuscular blocking agents alone should not be used to terminate seizures since they abolish the musculoskeletal manifestations without terminating seizure activity in the brain.
  • Anticipate Need for Anticonvulsants In patients with theophylline overdose who are at high risk for theophylline-induced seizures, e.g., patients with acute overdoses and serum theophylline concentrations >100 mcg/mL or chronic overdosage in patients >60 years of age with serum theophylline concentrations >30 mcg/mL, the need for anticonvulsant therapy should be anticipated. A benzodiazepine such as diazepam should be drawn into a syringe and kept at the patient's bedside and medical personnel qualified to treat seizures should be immediately available. In selected patients at high risk for theophylline-induced seizures, consideration should be given to the administration of prophylactic anticonvulsant therapy. Situations where prophylactic anticonvulsant therapy should be considered in high risk patients include anticipated delays in instituting methods for extracorporeal removal of theophylline (e.g., transfer of a high risk patient from one health care facility to another for extracorporeal removal) and clinical circumstances that significantly interfere with efforts to enhance theophylline clearance (e.g., a neonate where dialysis may not be technically feasible or a patient with vomiting unresponsive to antiemetics who is unable to tolerate multiple-dose oral activated charcoal). In animal studies, prophylactic administration of phenobarbital, but not phenytoin , has been shown to delay the onset of theophylline-induced generalized seizures and to increase the dose of theophylline required to induce seizures (i.e., markedly increases the LD50). Although there are no controlled studies in humans, a loading dose of intravenous phenobarbital (20 mg/kg infused over 60 minutes) may delay or prevent life-threatening seizures in high risk patients while efforts to enhance theophylline clearance are continued. Phenobarbital may cause respiratory depression, particularly in elderly patients and patients with COPD.
  • Treatment of cardiac arrhythmias Sinus tachycardia and simple ventricular premature beats are not harbingers of life-threatening arrhythmias, they do not require treatment in the absence of hemodynamic compromise, and they resolve with declining serum theophylline concentrations. Other arrhythmias, especially those associated with hemodynamic compromise, should be treated with antiarrhythmic therapy appropriate for the type of arrhythmia.
  • Serum Theophylline Concentration Monitoring The serum theophylline concentration should be measured immediately upon presentation, 2 - 4 hours later, and then at sufficient intervals, e.g., every 4 hours, to guide treatment decisions and to assess the effectiveness of therapy. Serum theophylline concentrations may continue to increase after presentation of the patient for medical care as a result of continued absorption of theophylline from the gastrointestinal tract. Serial monitoring of serum theophylline serum concentrations should be continued until it is clear that the concentration is no longer rising and has returned to nontoxic levels.
  • General Monitoring Procedures Electrocardiographic monitoring should be initiated on presentation and continued until the serum theophylline level has returned to a nontoxic level. Serum electrolytes and glucose should be measured on presentation and at appropriate intervals indicated by clinical circumstances. Fluid and electrolyte abnormalities should be promptly corrected. Monitoring and treatment should be continued until the serum concentration decreases below 20 mcg/mL.
  • Enhance clearance of theophylline Multiple-dose oral activated charcoal (e.g., 0.5 mg/kg up to 20 g, every two hours) increases the clearance of theophylline at least twofold by adsorption of theophylline secreted into gastrointestinal fluids. Charcoal must be retained in, and pass through, the gastrointestinal tract to be effective; emesis should therefore be controlled by administration of appropriate antiemetics. Alternatively, the charcoal can be administered continuously through a nasogastric tube in conjunction with appropriate antiemetics. A single dose of sorbitol may be administered with the activated charcoal to promote stooling to facilitate clearance of the adsorbed theophylline from the gastrointestinal tract. Sorbitol alone does not enhance clearance of theophylline and should be dosed with caution to prevent excessive stooling which can result in severe fluid and electrolyte imbalances. Commercially available fixed combinations of liquid charcoal and sorbitol should be avoided in young children and after the first dose in adolescents and adults since they do not allow for individualization of charcoal and sorbitol dosing. In patients with intractable vomiting, extracorporeal methods of theophylline removal should be instituted (see OVERDOSAGE , Extracorporeal Removal ).

Specific Recommendations:

Acute Overdose (e.g., excessive loading dose or excessive infusion rate <24 hours)

  • Serum Concentration >20 <30 mcg/mL
    • Stop the theophylline infusion.
    • Monitor the patient and obtain a serum theophylline concentration in 2 - 4 hours to insure that the concentration is decreasing.
  • Serum Concentration >30 <100 mcg/mL
    • Stop the theophylline infusion.
    • Administer multiple dose oral activated charcoal and measures to control emesis.
    • Monitor the patient and obtain serial theophylline concentrations every 2 - 4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.
    • Institute extracorporeal removal if emesis, seizures, or cardiac arrhythmias cannot be adequately controlled (see OVERDOSAGE , Extracorporeal Removal ).
  • Serum Concentration >100 mcg/mL
    • Stop the theophylline infusion.
    • Consider prophylactic anticonvulsant therapy.
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Consider extracorporeal removal, even if the patient has not experienced a seizure (see OVERDOSAGE , Extracorporeal Removal ).
    • Monitor the patient and obtain serial theophylline concentrations every 2 - 4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.

Chronic Overdosage (e.g., excessive infusion rate for greater than 24 hours)

  • Serum Concentration >20 <30 mcg/mL (with manifestations of theophylline toxicity)
    • Stop the theophylline infusion.
    • Monitor the patient and obtain a serum theophylline concentration in 2 - 4 hours to insure that the concentration is decreasing.
  • Serum Concentration >30 mcg/mL in patients <60 years of age
    • Stop the theophylline infusion.
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Monitor the patient and obtain serial theophylline concentrations every 2 - 4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.
    • Institute extracorporeal removal if emesis, seizures, or cardiac arrhythmias cannot be adequately controlled (see OVERDOSAGE , Extracorporeal Removal ).
  • Serum Concentration >30 mcg/mL in patients ≥60 years of age
    • Stop the theophylline infusion.
    • Consider prophylactic anticonvulsant therapy.
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Consider extracorporeal removal even if the patient has not experienced a seizure (see OVERDOSAGE , Extracorporeal Removal ).
    • Monitor the patient and obtain serial theophylline concentrations every 2 - 4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.

Extracorporeal Removal:

Increasing the rate of theophylline clearance by extracorporeal methods may rapidly decrease serum concentrations, but the risks of the procedure must be weighed against the potential benefit. Charcoal hemoperfusion is the most effective method of extracorporeal removal, increasing theophylline clearance up to six fold, but serious complications, including hypotension, hypocalcemia, platelet consumption and bleeding diatheses may occur. Hemodialysis is about as efficient as multiple-dose oral activated charcoal and has a lower risk of serious complications than charcoal hemoperfusion. Hemodialysis should be considered as an alternative when charcoal hemoperfusion is not feasible and multiple-dose oral charcoal is ineffective because of intractable emesis. Serum theophylline concentrations may rebound 5 - 10 mcg/mL after discontinuation of charcoal hemoperfusion or hemodialysis due to redistribution of theophylline from the tissue compartment. Peritoneal dialysis is ineffective for theophylline removal; exchange transfusions in neonates have been minimally effective.

DOSAGE AND ADMINISTRATION

General Considerations:

The steady-state serum theophylline concentration is a function of the infusion rate and the rate of theophylline clearance in the individual patient. Because of marked individual differences in the rate of theophylline clearance, the dose required to achieve a serum theophylline concentration in the 10-20 mcg/mL range varies fourfold among otherwise similar patients in the absence of factors known to alter theophylline clearance. For a given population there is no single theophylline dose that will provide both safe and effective serum concentrations for all patients. Administration of the median theophylline dose required to achieve a therapeutic serum theophylline concentration in a given population may result in either sub-therapeutic or potentially toxic serum theophylline concentrations in individual patients. The dose of theophylline must be individualized on the basis of serum theophylline concentration measurements in order to achieve a dose that will provide maximum potential benefit with minimal risk of adverse effects.

When theophylline is used as an acute bronchodilator, the goal of obtaining a therapeutic serum concentration is best accomplished with an intravenous loading dose. Because of rapid distribution into body fluids, the serum concentration (C) obtained from an initial loading dose (LD) is related primarily to the volume of distribution (V), the apparent space into which the drug diffuses:

C = LD/V

If a mean volume of distribution of about 0.5 L/kg is assumed (actual range is 0.3 to 0.7 L/kg), each mg/kg (ideal body weight) of theophylline administered as a loading dose over 30 minutes results in an average 2 mcg/mL increase in serum theophylline concentration. Therefore, in a patient who has received no theophylline in the previous 24 hours, a loading dose of intravenous theophylline of 4.6 mg/kg (5.7 mg/kg as Euphyllin (Aminophylline Hydrate)), calculated on the basis of ideal body weight and administered over 30 minutes, on average, will produce a maximum post-distribution serum concentration of 10 mcg/mL with a range of 6-16 mcg/mL. When a loading dose becomes necessary in the patient who has already received theophylline, estimation of the serum concentration based upon the history is unreliable, and an immediate serum level determination is indicated. The loading dose can then be determined as follows:

D = (Desired C - Measured C) (V)

where D is the loading dose, C is the serum theophylline concentration, and V is the volume of distribution. The mean volume of distribution can be assumed to be 0.5 L/kg and the desired serum concentration should be conservative (e.g., 10 mcg/mL) to allow for the variability in the volume of distribution. A loading dose should not be given before obtaining a serum theophylline concentration if the patient has received any theophylline in the previous 24 hours.

A serum concentration obtained 30 minutes after an intravenous loading dose, when distribution is complete, can be used to assess the need for and size of subsequent loading doses, if clinically indicated, and for guidance of continuing therapy. Once a serum concentration of 10 to 15 mcg/mL has been achieved with the use of a loading dose(s), a constant intravenous infusion is started. The rate of administration is based upon mean pharmacokinetic parameters for the population and calculated to achieve a target serum concentration of 10 mcg/mL (see Table V ). For example, in non-smoking adults, initiation of a constant intravenous theophylline infusion of 0.4 mg/kg/hr (0.5 mg/kg/hr as Euphyllin (Aminophylline Hydrate)) at the completion of the loading dose, on average, will result in a steady-state concentration of 10 mcg/mL with a range of 7-26 mcg/mL. The mean and range of steady-state serum concentrations are similar when the average child (age 1 to 9 years) is given a loading dose of 4.6 mg/kg theophylline (5.7 mg/kg as Euphyllin (Aminophylline Hydrate)) followed by a constant intravenous infusion of 0.8 mg/kg/hr (1.0 mg/kg/hr as Euphyllin (Aminophylline Hydrate)). Since there is large interpatient variability in theophylline clearance, serum concentrations will rise or fall when the patient's clearance is significantly different from the mean population value used to calculate the initial infusion rate. Therefore, a second serum concentration should be obtained one expected half-life after starting the constant infusion (e.g., approximately 4 hours for children age 1 to 9 and 8 hours for nonsmoking adults; See Table I for the expected half-life in additional patient populations) to determine if the concentration is accumulating or declining from the post loading dose level. If the level is declining as a result of a higher than average clearance, an additional loading dose can be administered and/or the infusion rate increased. In contrast, if the second sample demonstrates a higher level, accumulation of the drug can be assumed, and the infusion rate should be decreased before the concentration exceeds 20 mcg/mL. An additional sample is obtained 12 to 24 hours later to determine if further adjustments are required and then at 24-hour intervals to adjust for changes, if they occur. This empiric method, based upon mean pharmacokinetic parameters, will prevent large fluctuations in serum concentration during the most critical period of the patient's course.

In patients with cor pulmonale, cardiac decompensation, or liver dysfunction, or in those taking drugs that markedly reduce theophylline clearance (e.g., cimetidine), the initial theophylline infusion rate should not exceed 17 mg/hr (21 mg/hr as Euphyllin (Aminophylline Hydrate)) unless serum concentrations can be monitored at 24-hour intervals. In these patients, 5 days may be required before steady-state is reached.

Theophylline distributes poorly into body fat, therefore, mg/kg dose should be calculated on the basis of ideal body weight.

Table V contains initial theophylline infusion rates following an appropriate loading dose recommended for patients in various age groups and clinical circumstances. Table VI contains recommendations for final theophylline dosage adjustment based upon serum theophylline concentrations. Application of these general dosing recommendations to individual patients must take into account the unique clinical characteristics of each patient. In general, these recommendations should serve as the upper limit for dosage adjustments in order to decrease the risk of potentially serious adverse events associated with unexpected large increases in serum theophylline concentration.

* To achieve a target concentration of 10 mcg/mL Aminophylline=theophylline/0.8. Use ideal body weight for obese patients.

† Lower initial dosage may be required for patients receiving other drugs that decrease theophylline clearance (e.g., cimetidine).

‡ To achieve a target concentration of 7.5 mcg/mL for neonatal apnea.

§ Not to exceed 900 mg/day, unless serum levels indicate the need for a larger dose.

ı Not to exceed 400 mg/day, unless serum levels indicate the need for a larger dose.


Patient population


Age


Theophylline infusion rate (mg/kg/hr)*†


Neonates


Postnatal age up to 24 days

Postnatal age beyond 24 days


1 mg/kg q12h/‡

1.5 mg/kg q12h/‡


Infants


6-52 weeks old


mg/kg/hr= (0.008)(age in weeks) + 0.21


Young children


1-9 years


0.8


Older children


9-12 years


0.7


Adolescents

(cigarette or marijuana

smokers)


12-16 years


0.7


Adolescents (nonsmokers)


12-16 years


0.5 §


Adults

(otherwise healthy

nonsmokers)


16-60 years


0.4 §


Elderly


>60 years


0.3 ı


Cardiac decompensation,

cor pulmonale, liver

dysfunction, sepsis with

multiorgan failure,

or shock


0.2 ı

¶ Dose reduction and/or serum theophylline concentration measurement is indicated whenever adverse effects are present, physiologic abnormalities that can reduce theophylline clearance occur (e.g., sustained fever), or a drug that interacts with theophylline is added or discontinued (see WARNINGS ).

Peak Serum Concentration


Dosage Adjustment


<9.9 mcg/mL


If symptoms are not controlled and current dosage is tolerated, increase infusion rate about 25%. Recheck serum concentration after 12 hours in children and 24 hours in adults for further dosage adjustment.


10 to 14.9 mcg/mL


If symptoms are controlled and current dosage is tolerated, maintain infusion rate and recheck serum concentration at 24 hour intervals.¶ If symptoms are not controlled and current dosage is tolerated consider adding additional medication(s) to treatment regimen.


15-19.9 mcg/mL


Consider 10% decrease in infusion rate to provide greater margin of safety even if current dosage is tolerated.¶


20-24.9 mcg/mL


Decrease infusion rate by 25% even if no adverse effects are present. Recheck serum concentration after 12 hours in children and 24 hours in adults to guide further dosage adjustment.


25-30 mcg/mL


Stop infusion for 12 hours in children and 24 hours in adults and decrease subsequent infusion rate at least 25% even if no adverse effects are present. Recheck serum concentration after 12 hours in children and 24 hours in adults to guide further dosage adjustment. If symptomatic, stop infusion and consider whether overdose treatment is indicated.


>30 mcg/mL


Stop the infusion and treat overdose as indicated. If theophylline is subsequently resumed, decrease infusion rate by at least 50% and recheck serum concentration after 12 hours in children and 24 hours in adults to guide further dosage adjustment.


Intravenous Admixture Incompatibility:

Although there have been reports of Euphyllin (Aminophylline Hydrate) precipitating in acidic media, these reports do not apply to the dilute solutions found in intravenous infusions. Euphyllin (Aminophylline Hydrate) injection should not be mixed in a syringe with other drugs but should be added separately to the intravenous solution.

When an intravenous solution containing Euphyllin (Aminophylline Hydrate) is given "piggyback", the intravenous system already in place should be turned off while the Euphyllin (Aminophylline Hydrate) is infused if there is a potential problem with admixture incompatibility.

Because of the alkalinity of Euphyllin (Aminophylline Hydrate) containing solutions, drugs known to be alkali labile should be avoided in admixtures. These include epinephrine HCl, norepinephrine bitartrate, isoproterenol HCl and penicillin G potassium. It is suggested that specialized literature be consulted before preparing admixtures with Euphyllin (Aminophylline Hydrate) and other drugs.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not administer unless solution is clear and container is undamaged. Discard unused portion. Do not use if crystals have separated from solution.

HOW SUPPLIED

Euphyllin (Aminophylline Hydrate) Injection, USP 25 mg/mL is supplied in single-dose containers as follows:


NDC No.


Container


Volume


Total Content


0409-7385-01


Ampul


10 mL


250 mg


0409-7386-01


Ampul


20 mL


500 mg


0409-5921-01


Partial-fill Fliptop Vial


10 mL


250 mg


0409-5922-01


Partial-fill Fliptop Vial


20 mL


500 mg


Store at 20 to 25°C (68 to 77°F).

PROTECT FROM LIGHT. Store in carton until time of use.

SINGLE-DOSE CONTAINER. Discard unused portion.


Revised: November, 2009




Printed in USA EN-2301

Hospira, Inc., Lake Forest, IL 60045 USA

Hospira logo

10 mL Single-dose

Euphyllin (Aminophylline Hydrate)

Inj., USP

250 mg (25 mg/mL)

Protect from light.

Do not use if crystals have

separated from solution.

HOSPIRA, INC., LAKE FOREST, IL 60045 USA

Rx only

10 mL Single-dose Ampul

25/NDC 0409-7385-01

Euphyllin (Aminophylline Hydrate)

Injection, USP

250 mg (25 mg/mL)

Protect from light.

Each mL contains Euphyllin (Aminophylline Hydrate) (calculated as the dihydrate) 25 mg

(equivalent to 19.7 mg/mL of anhydrous theophylline). May contain an

excess of ethylenediamine for pH adjustment. pH 8.8 (8.6 to 9.0).

Sterile, nonpyrogenic. Protect from light by retaining in carton until ready

for use. Do not use if crystals have separated from solution.

For I.V. use. Usual dose: See insert. Store at controlled room temperature

15° to 30°C (59° to 86°F).

©Hospira 2004

RL-0277 (6/04)

Printed in USA

HOSPIRA, INC., LAKE FOREST, IL 60045 USA

Rx only

Hospira

20 mL

Single-dose

Ampul

Euphyllin (Aminophylline Hydrate)

Inj., USP

500 mg (25 mg/mL)

Protect from light.

DO NOT USE IF CRYSTALS HAVE

SEPARATED FROM SOLUTION.

HOSPIRA, INC., LAKE FOREST, IL 60045 USA

Rx only

20 mL Single-dose Ampul

25/NDC 0409-7386-01

Rx only

Euphyllin (Aminophylline Hydrate)

Injection, USP

500 mg (25 mg/mL)

Protect from light.

Each mL contains Euphyllin (Aminophylline Hydrate) (calculated as the dihydrate) 25 mg

(equivalent to 19.7 mg/mL of anhydrous theophylline). May contain an

excess of ethylenediamine for pH adjustment. pH 8.8 (8.6 to 9.0).

Headspace nitrogen gassed. Sterile, nonpyrogenic. Protect from light

by retaining in carton until ready for use. Do not use if crystals have

separated from solution. For I.V. use. Usual dose: See insert. Store at

20 to 25°C (68 to 77°F).

Printed in USA

RL-3070

Hospira, Inc., Lake Forest, IL 60045 USA

Hospira

10 mL Single-dose

Euphyllin (Aminophylline Hydrate)

Injection, USP

250 mg (25 mg/mL)

Protect from light.

DO NOT USE IF CRYSTALS HAVE

SEPARATED FROM SOLUTION.

HOSPIRA, INC., LAKE FOREST, IL 60045 USA

Rx only

Theophylline:


DESCRIPTION

Euphyllin (Theophylline)® (theophylline, anhydrous) Tablets in a controlled-release system allows a 24-hour dosing interval for appropriate patients.

Euphyllin (Theophylline) is structurally classified as a methylxanthine. It occurs as a white, odorless, crystalline powder with a bitter taste. Anhydrous Euphyllin (Theophylline) has the chemical name 1H-Purine-2,6-dione, 3,7-dihydro-1,3-dimethyl-, and is represented by the following structural formula:

The molecular formula of anhydrous Euphyllin (Theophylline) is C7H8N4O2 with a molecular weight of 180.17.

Each controlled-release tablet for oral administration, contains 400 or 600 mg of anhydrous Euphyllin (Theophylline).

Inactive Ingredients: cetostearyl alcohol, hydroxyethyl cellulose, magnesium stearate, povidone and talc.

Euphyllin (Theophylline) 400 mg

CLINICAL PHARMACOLOGY

Mechanism of Action

Euphyllin has two distinct actions in the airways of patients with reversible obstruction; smooth muscle relaxation (i.e., bronchodilation) and suppression of the response of the airways to stimuli (i.e., non-bronchodilator prophylactic effects). While the mechanisms of action of Euphyllin (Theophylline) are not known with certainty, studies in animals suggest that bronchodilatation is mediated by the inhibition of two isozymes of phosphodiesterase (PDE III and, to a lesser extent, PDE IV) while non-bronchodilator prophylactic actions are probably mediated through one or more different molecular mechanisms, that do not involve inhibition of PDE III or antagonism of adenosine receptors. Some of the adverse effects associated with Euphyllin (Theophylline) appear to be mediated by inhibition of PDE III (e.g., hypotension, tachycardia, headache, and emesis) and adenosine receptor antagonism (e.g., alterations in cerebral blood flow).

Euphyllin (Theophylline) increases the force of contraction of diaphragmatic muscles. This action appears to be due to enhancement of calcium uptake through an adenosine-mediated channel.

Serum Concentration-Effect Relationship

Bronchodilation occurs over the serum Euphyllin (Theophylline) concentration range of 5-20 mcg/mL. Clinically important improvement in symptom control has been found in most studies to require peak serum Euphyllin (Theophylline) concentrations >10 mcg/mL, but patients with mild disease may benefit from lower concentrations. At serum Euphyllin (Theophylline) concentrations >20 mcg/mL, both the frequency and severity of adverse reactions increase. In general, maintaining peak serum Euphyllin (Theophylline) concentrations between 10 and 15 mcg/mL will achieve most of the drug’s potential therapeutic benefit while minimizing the risk of serious adverse events.

Pharmacokinetics

Overview: Euphyllin is rapidly and completely absorbed after oral administration in solution or immediate-release solid oral dosage form. Euphyllin (Theophylline) does not undergo any appreciable pre-systemic elimination, distributes freely into fat-free tissues and is extensively metabolized in the liver.

The pharmacokinetics of Euphyllin (Theophylline) vary widely among similar patients and cannot be predicted by age, sex, body weight or other demographic characteristics. In addition, certain concurrent illnesses and alterations in normal physiology (see Table I ) and co-administration of other drugs (see Table II ) can significantly alter the pharmacokinetic characteristics of Euphyllin (Theophylline). Within-subject variability in metabolism has also been reported in some studies, especially in acutely ill patients. It is, therefore, recommended that serum Euphyllin (Theophylline) concentrations be measured frequently in acutely ill patients (e.g., at 24-hr intervals) and periodically in patients receiving long-term therapy, e.g., at 6-12 month intervals. More frequent measurements should be made in the presence of any condition that may significantly alter Euphyllin (Theophylline) clearance (see PRECAUTIONS, Laboratory Tests ).

Population Characteristics Total body clearance*

mean (range)††

(mL/kg/min)

Half-life mean (range)††

(hr)

For various North American patient populations from literature reports. Different rates of elimination and consequent dosage requirements have been observed among other peoples.
*Clearance represents the volume of blood completely cleared of Euphyllin (Theophylline) by the liver in one minute. Values listed were generally determined at serum Euphyllin (Theophylline) concentrations <20 mcg/mL; clearance may decrease and half-life may increase at higher serum concentrations due to non-linear pharmacokinetics.
††Reported range or estimated range (mean ±2 SD) where actual range not reported.
†NR=not reported or not reported in a comparable format.
**Median
Age
Premature neonates
postnatal age 3-15 days 0.29 (0.09-0.49) 30 (17-43)
postnatal age 25-57 days 0.64 (0.04-1.2) 20 (9.4-30.6)
Term infants
postnatal age 1-2 days NR 25.7 (25-26.5)
postnatal age 3-30 weeks NR 11 (6-29)
Children
1-4 years 1.7 (0.5-2.9) 3.4 (1.2-5.6)
4-12 years 1.6 (0.8-2.4) NR
13-15 years 0.9 (0.48-1.3) NR
6-17 years 1.4 (0.2-2.6) 3.7 (1.5-5.9)
Adults (16-60 years)
otherwise healthy
non-smoking asthmatics 0.65 (0.27-1.03) 8.7 (6.1-12.8)
Elderly (>60 years)
non-smokers with normal

cardiac,

liver, and renal function

0.41 (0.21-0.61) 9.8 (1.6-18)
Concurrent illness or altered physiological state
Acute pulmonary edema 0.33** (0.07-2.45) 19** (3.1-82)
COPD->60 years, stable
non-smoker >1 year 0.54 (0.44-0.64) 11 (9.4-12.6)
COPD with cor pulmonale 0.48 (0.08-0.88) NR
Cystic fibrosis (14-28 years) 1.25 (0.31-2.2) 6.0 (1.8-10.2)
Fever associated with
acute viral respiratory illness
(children 9-15 years) NR 7.0 (1.0-13)
Liver disease
cirrhosis 0.31** (0.1-0.7) 32** (10-56)
acute hepatitis 0.35 (0.25-0.45) 19.2 (16.6-21.8)
cholestasis 0.65 (0.25-1.45) 14.4 (5.7-31.8)
Pregnancy
1st trimester NR 8.5 (3.1-13.9)
2nd trimester NR 8.8 (3.8-13.8)
3rd trimester NR 13.0 (8.4-17.6)
Sepsis with multi-organ failure 0.47 (0.19-1.9) 18.8 (6.3-24.1)
Thyroid disease
hypothyroid 0.38 (0.13-0.57) 11.6 (8.2-25)
hyperthyroid 0.8 (0.68-0.97) 4.5 (3.7-5.6)

Note: In addition to the factors listed above, Euphyllin (Theophylline) clearance is increased and half-life decreased by low carbohydrate/high protein diets, parenteral nutrition, and daily consumption of charcoal-broiled beef. A high carbohydrate/low protein diet can decrease the clearance and prolong the half-life of Euphyllin (Theophylline).

Absorption

Euphyllin (Theophylline)® administered in the fed state is completely absorbed after oral administration.

In a single-dose crossover study, two 400 mg Euphyllin (Theophylline) Tablets were administered to 19 normal volunteers in the morning or evening immediately following the same standardized meal (769 calories consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat). There was no evidence of dose dumping nor were there any significant differences in pharmacokinetic parameters attributable to time of drug administration. On the morning arm, the pharmacokinetic parameters were AUC=241.9±83.0 mcg hr/mL, Cmax=9.3±2.0 mcg/mL, Tmax=12.8±4.2 hours. On the evening arm, the pharmacokinetic parameters were AUC=219.7±83.0 mcg hr/mL, Cmax=9.2±2.0 mcg/mL, Tmax=12.5±4.2 hours.

A study in which Euphyllin (Theophylline) 400 mg Tablets were administered to 17 fed adult asthmatics produced similar Euphyllin (Theophylline) level-time curves when administered in the morning or evening. Serum levels were generally higher in the evening regimen but there were no statistically significant differences between the two regimens.

MORNING EVENING
AUC (0-24 hrs) (mcg hr/mL) 236.0±76.7 256.0±80.4
Cmax (mcg/mL) 14.5±4.1 16.3±4.5
Cmin (mcg/mL) 5.5±2.9 5.0±2.5
Tmax (hours) 8.1±3.7 10.1±4.1

A single-dose study in 15 normal fasting male volunteers whose Euphyllin (Theophylline) inherent mean elimination half-life was verified by a liquid Euphyllin (Theophylline) product to be 6.9±2.5 (SD) hours were administered two or three 400 mg Euphyllin (Theophylline)® Tablets. The relative bioavailability of Euphyllin (Theophylline) given in the fasting state in comparison to an immediate-release product was 59%. Peak serum Euphyllin (Theophylline) levels occurred at 6.9±5.2 (SD) hours, with a normalized (to 800 mg) peak level being 6.2±2.1 (SD). The apparent elimination half-life for the 400 mg Euphyllin (Theophylline) Tablets was 17.2±5.8 (SD) hours.

Steady-state pharmacokinetics were determined in a study in 12 fasted patients with chronic reversible obstructive pulmonary disease. All were dosed with two 400 mg Euphyllin (Theophylline) Tablets given once daily in the morning and a reference controlled-release BID product administered as two 200 mg tablets given 12 hours apart. The pharmacokinetic parameters obtained for Euphyllin (Theophylline) Tablets given at doses of 800 mg once daily in the morning were virtually identical to the corresponding parameters for the reference drug when given as 400 mg BID. In particular, the AUC, Cmax and Cmin values obtained in this study were as follows:

Euphyllin (Theophylline) Tablets

800 mg

Q24h±SD

Reference Drug

400 mg

Q12h±SD

AUC, (0-24 hours), mcg hr/mL 288.9±21.5 283.5±38.4
Cmax, mcg/mL 15.7±2.8 15.2±2.1
Cmin, mcg/mL 7.9±1.6 7.8±1.7
Cmax-Cmin diff. 7.7±1.5 7.4±1.5

Single-dose studies in which subjects were fasted for twelve (12) hours prior to and an additional four (4) hours following dosing, demonstrated reduced bioavailability as compared to dosing with food. One single-dose study in 20 normal volunteers dosed with two (2) 400 mg tablets in the morning, compared dosing under these fasting conditions with dosing immediately prior to a standardized breakfast (769 calories, consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat). Under fed conditions, the pharmacokinetic parameters were: AUC=231.7±92.4 mcg hr/mL, Cmax=8.4±2.6 mcg/mL, Tmax=17.3±6.7 hours. Under fasting conditions, these parameters were AUC=141.2±6.53 mcg hr/mL, Cmax=5.5±1.5 mcg/mL, Tmax=6.5±2.1 hours.

Another single-dose study in 21 normal male volunteers, dosed in the evening, compared fasting to a standardized high calorie, high fat meal (870-1,020 calories, consisting of 33 grams protein, 55-75 grams fat, 58 grams carbohydrates). In the fasting arm subjects received one Euphyllin (Theophylline)® 400 mg Tablet at 8 p.m. after an eight hour fast followed by a further four hour fast. In the fed arm, subjects were again dosed with one 400 mg Euphyllin (Theophylline) Tablet, but at 8 p.m. immediately after the high fat content standardized meal cited above. The pharmacokinetic parameters (normalized to 800 mg) fed were AUC=221.8±40.9 mcg hr/mL, Cmax=10.9±1.7 mcg/mL, Tmax=11.8±2.2 hours. In the fasting arm, the pharmacokinetic parameters (normalized to 800 mg) were AUC=146.4±40.9 mcg hr/mL, Cmax=6.7±1.7 mcg/mL, Tmax=7.3±2.2 hours.

Thus, administration of single Euphyllin (Theophylline) doses to healthy normal volunteers, under prolonged fasted conditions (at least 10 hour overnight fast before dosing followed by an additional four (4) hour fast after dosing) results in decreased bioavailability. However, there was no failure of this delivery system leading to a sudden and unexpected release of a large quantity of Euphyllin (Theophylline) with Euphyllin (Theophylline) Tablets even when they are administered with a high fat, high calorie meal.

Similar studies were conducted with the 600 mg Euphyllin (Theophylline) Tablet. A single-dose study in 24 subjects with an established Euphyllin (Theophylline) clearance of ≤4 L/hr, compared the pharmacokinetic evaluation of one 600 mg Euphyllin (Theophylline) Tablet and one and one-half 400 mg Euphyllin (Theophylline) Tablets under fed (using a standard high fat diet) and fasted conditions. The results of this 4-way randomized crossover study demonstrate the bioequivalence of the 400 mg and 600 mg Euphyllin (Theophylline) Tablets. Under fed conditions, the pharmacokinetic results for the one and one-half 400 mg tablets were AUC=214.64±55.88 mcg hr/mL, Cmax=10.58±2.21 mcg/mL and Tmax=9.00±2.64 hours, and for the 600 mg tablet were AUC=207.85±48.9 mcg hr/mL, Cmax=10.39±1.91 mcg/mL and Tmax=9.58±1.86 hours. Under fasted conditions the pharmacokinetic results for the one and one-half 400 mg tablets were AUC=191.85 ±51.1 mcg hr/mL, Cmax= 7.37±1.83 mcg/mL and Tmax=8.08±4.39 hours; and for the 600 mg tablet were AUC=199.39±70.27 mcg hr/mL, Cmax=7.66±2.09 mcg/mL and Tmax=9.67±4.89 hours.

In this study the mean fed/fasted ratios for the one and one-half 400 mg tablets and the 600 mg tablet were about 112% and 104%, respectively.

In another study, the bioavailability of the 600 mg Euphyllin (Theophylline) Tablet was examined with morning and evening administration. This single-dose, crossover study in 22 healthy males was conducted under fed (standard high fat diet) conditions. The results demonstrated no clinically significant difference in the bioavailability of the 600 mg Euphyllin (Theophylline) Tablet administered in the morning or in the evening. The results were: AUC=233.6±45.1 mcg hr/mL, Cmax=10.6±1.3 mcg/mL and Tmax=12.5±3.2 hours with morning dosing; AUC=209.8±46.2 mcg hr/mL, Cmax=9.7±1.4 mcg/mL and Tmax=13.7±3.3 hours with evening dosing. The PM/AM ratio was 89.3%.

The absorption characteristics of Euphyllin (Theophylline)® Tablets (theophylline, anhydrous) have been extensively studied. A steady-state crossover bioavailability study in 22 normal males compared two Euphyllin (Theophylline) 400 mg Tablets administered q24h at 8 a.m. immediately after breakfast with a reference controlled-release Euphyllin (Theophylline) product administered BID in fed subjects at 8 a.m. immediately after breakfast and 8 p.m. immediately after dinner (769 calories, consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat).

The pharmacokinetic parameters for Euphyllin (Theophylline) 400 mg Tablets under these steady-state conditions were AUC=203.3±87.1 mcg hr/mL, Cmax=12.1±3.8 mcg/mL, Cmin=4.50±3.6, Tmax=8.8±4.6 hours. For the reference BID product, the pharmacokinetic parameters were AUC=219.2±88.4 mcg hr/mL, Cmax =11.0±4.1 mcg/mL, Cmin=7.28±3.5, Tmax=6.9±3.4 hours. The mean percent fluctuation [(Cmax-Cmin/Cmin)x100]=169% for the once-daily regimen and 51% for the reference product BID regimen.

The bioavailability of the 600 mg Euphyllin (Theophylline) Tablet was further evaluated in a multiple dose, steady-state study in 26 healthy males comparing the 600 mg Tablet to one and one-half 400 mg Euphyllin (Theophylline) Tablets. All subjects had previously established Euphyllin (Theophylline) clearances of ≤4 L/hr and were dosed once-daily for 6 days under fed conditions. The results showed no clinically significant difference between the 600 mg and one and one-half 400 mg Euphyllin (Theophylline) Tablet regimens. Steady-state results were:

600 MG TABLET

FED

600 MG

(ONE+ONE-HALF

400 MG TABLETS)

FED

AUC 0-24hrs (mcg hr/mL) 209.77±51.04 212.32±56.29
Cmax (mcg/mL) 12.91±2.46 13.17±3.11
Cmin (mcg/mL) 5.52±1.79 5.39±1.95
Tmax (hours) 8.62±3.21 7.23±2.35
Percent Fluctuation 183.73±54.02 179.72±28.86

The bioavailability ratio for the 600/400 mg tablets was 98.8%. Thus, under all study conditions the 600 mg tablet is bioequivalent to one and one-half 400 mg tablets.

Studies demonstrate that as long as subjects were either consistently fed or consistently fasted, there is similar bioavailability with once-daily administration of Euphyllin (Theophylline) Tablets whether dosed in the morning or evening.

Distribution

Once Euphyllin enters the systemic circulation, about 40% is bound to plasma protein, primarily albumin. Unbound Euphyllin (Theophylline) distributes throughout body water, but distributes poorly into body fat. The apparent volume of distribution of Euphyllin (Theophylline) is approximately 0.45 L/kg (range 0.3-0.7 L/kg) based on ideal body weight. Euphyllin (Theophylline) passes freely across the placenta, into breast milk and into the cerebrospinal fluid (CSF). Saliva Euphyllin (Theophylline) concentrations approximate unbound serum concentrations, but are not reliable for routine or therapeutic monitoring unless special techniques are used. An increase in the volume of distribution of Euphyllin (Theophylline), primarily due to reduction in plasma protein binding, occurs in premature neonates, patients with hepatic cirrhosis, uncorrected acidemia, the elderly and in women during the third trimester of pregnancy. In such cases, the patient may show signs of toxicity at total (bound+unbound) serum concentrations of Euphyllin (Theophylline) in the therapeutic range (10-20 mcg/mL) due to elevated concentrations of the pharmacologically active unbound drug. Similarly, a patient with decreased Euphyllin (Theophylline) binding may have a sub-therapeutic total drug concentration while the pharmacologically active unbound concentration is in the therapeutic range. If only total serum Euphyllin (Theophylline) concentration is measured, this may lead to an unnecessary and potentially dangerous dose increase. In patients with reduced protein binding, measurement of unbound serum Euphyllin (Theophylline) concentration provides a more reliable means of dosage adjustment than measurement of total serum Euphyllin (Theophylline) concentration. Generally, concentrations of unbound Euphyllin (Theophylline) should be maintained in the range of 6-12 mcg/mL.

Metabolism

Following oral dosing, Euphyllin (Theophylline) does not undergo any measurable first-pass elimination. In adults and children beyond one year of age, approximately 90% of the dose is metabolized in the liver. Biotransformation takes place through demethylation to 1-methylxanthine and 3-methylxanthine and hydroxylation to 1,3-dimethyluric acid. 1-methylxanthine is further hydroxylated, by xanthine oxidase, to 1-methyluric acid. About 6% of a Euphyllin (Theophylline) dose is N-methylated to caffeine. Euphyllin (Theophylline) demethylation to 3-methylxanthine is catalyzed by cytochrome P-450 1A2, while cytochromes P-450 2E1 and P-450 3A3 catalyze the hydroxylation to 1,3-dimethyluric acid. Demethylation to 1-methylxanthine appears to be catalyzed either by cytochrome P-450 1A2 or a closely related cytochrome. In neonates, the N-demethylation pathway is absent while the function of the hydroxylation pathway is markedly deficient. The activity of these pathways slowly increases to maximal levels by one year of age.

Caffeine and 3-methylxanthine are the only Euphyllin (Theophylline) metabolites with pharmacologic activity. 3-methylxanthine has approximately one tenth the pharmacologic activity of Euphyllin (Theophylline) and serum concentrations in adults with normal renal function are <1 mcg/mL. In patients with end-stage renal disease, 3-methylxanthine may accumulate to concentrations that approximate the unmetabolized Euphyllin (Theophylline) concentration. Caffeine concentrations are usually undetectable in adults regardless of renal function. In neonates, caffeine may accumulate to concentrations that approximate the unmetabolized Euphyllin (Theophylline) concentration and thus, exert a pharmacologic effect.

Both the N-demethylation and hydroxylation pathways of Euphyllin (Theophylline) biotransformation are capacity-limited. Due to the wide intersubject variability of the rate of Euphyllin (Theophylline) metabolism, non-linearity of elimination may begin in some patients at serum Euphyllin (Theophylline) concentrations <10 mcg/mL. Since this non-linearity results in more than proportional changes in serum Euphyllin (Theophylline) concentrations with changes in dose, it is advisable to make increases or decreases in dose in small increments in order to achieve desired changes in serum Euphyllin (Theophylline) concentrations (see DOSAGE AND ADMINISTRATION, Table VI ). Accurate prediction of dose-dependency of Euphyllin (Theophylline) metabolism in patients a priori is not possible, but patients with very high initial clearance rates (i.e., low steady-state serum Euphyllin (Theophylline) concentrations at above average doses) have the greatest likelihood of experiencing large changes in serum Euphyllin (Theophylline) concentration in response to dosage changes.

Excretion

In neonates, approximately 50% of the Euphyllin dose is excreted unchanged in the urine. Beyond the first three months of life, approximately 10% of the Euphyllin (Theophylline) dose is excreted unchanged in the urine. The remainder is excreted in the urine mainly as 1,3-dimethyluric acid (35-40%), 1-methyluric acid (20-25%) and 3-methylxanthine (15-20%). Since little Euphyllin (Theophylline) is excreted unchanged in the urine and since active metabolites of Euphyllin (Theophylline) (i.e., caffeine, 3-methylxanthine) do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, the large fraction of the Euphyllin (Theophylline) dose excreted in the urine as unchanged Euphyllin (Theophylline) and caffeine in neonates requires careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations in neonates with reduced renal function (See WARNINGS ).

Serum Concentrations at Steady-State

After multiple doses of Euphyllin (Theophylline), steady-state is reached in 30-65 hours (average 40 hours) in adults. At steady-state, on a dosage regimen with 24-hour intervals, the expected mean trough concentration is approximately 50% of the mean peak concentration, assuming a mean Euphyllin (Theophylline) half-life of 8 hours. The difference between peak and trough concentrations is larger in patients with more rapid Euphyllin (Theophylline) clearance. In these patients administration of Euphyllin (Theophylline)® may be required more frequently (every 12 hours).

Special Populations


Geriatric

The clearance of Euphyllin (Theophylline) is decreased by an average of 30% in healthy elderly adults (>60 yrs) compared to healthy young adults. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in elderly patients (see WARNINGS ).

Pediatrics

The clearance of Euphyllin is very low in neonates (see WARNINGS ). Euphyllin (Theophylline) clearance reaches maximal values by one year of age, remains relatively constant until about 9 years of age and then slowly decreases by approximately 50% to adult values at about age 16. Renal excretion of unchanged Euphyllin (Theophylline) in neonates amounts to about 50% of the dose, compared to about 10% in children older than three months and in adults. Careful attention to dosage selection and monitoring of serum Euphyllin (Theophylline) concentrations are required in pediatric patients (see WARNINGS and DOSAGE AND ADMINISTRATION ).

Gender

Gender differences in Euphyllin (Theophylline) clearance are relatively small and unlikely to be of clinical significance. Significant reduction in Euphyllin (Theophylline) clearance, however, has been reported in women on the 20th day of the menstrual cycle and during the third trimester of pregnancy.

Race

Pharmacokinetic differences in Euphyllin clearance due to race have not been studied.

Renal Insufficiency

Only a small fraction, e.g., about 10%, of the administered Euphyllin (Theophylline) dose is excreted unchanged in the urine of children greater than three months of age and adults. Since little Euphyllin (Theophylline) is excreted unchanged in the urine and since active metabolites of Euphyllin (Theophylline) (i.e., caffeine, 3-methylxanthine) do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, approximately 50% of the administered Euphyllin (Theophylline) dose is excreted unchanged in the urine in neonates. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in neonates with decreased renal function (see WARNINGS ).

Hepatic Insufficiency

Euphyllin clearance is decreased by 50% or more in patients with hepatic insufficiency (e.g., cirrhosis, acute hepatitis, cholestasis). Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in patients with reduced hepatic function (see WARNINGS ).

Congestive Heart Failure (CHF)

Euphyllin (Theophylline) clearance is decreased by 50% or more in patients with CHF. The extent of reduction in Euphyllin (Theophylline) clearance in patients with CHF appears to be directly correlated to the severity of the cardiac disease. Since Euphyllin (Theophylline) clearance is independent of liver blood flow, the reduction in clearance appears to be due to impaired hepatocyte function rather than reduced perfusion. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in patients with CHF (see WARNINGS ).

Smokers

Tobacco and marijuana smoking appears to increase the clearance of Euphyllin by induction of metabolic pathways. Euphyllin (Theophylline) clearance has been shown to increase by approximately 50% in young adult tobacco smokers and by approximately 80% in elderly tobacco smokers compared to non-smoking subjects. Passive smoke exposure has also been shown to increase Euphyllin (Theophylline) clearance by up to 50%. Abstinence from tobacco smoking for one week causes a reduction of approximately 40% in Euphyllin (Theophylline) clearance. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in patients who stop smoking (see WARNINGS ). Use of nicotine gum has been shown to have no effect on Euphyllin (Theophylline) clearance.

Fever

Fever, regardless of its underlying cause, can decrease the clearance of Euphyllin (Theophylline). The magnitude and duration of the fever appear to be directly correlated to the degree of decrease of Euphyllin (Theophylline) clearance. Precise data are lacking, but a temperature of 39°C (102°F) for at least 24 hours is probably required to produce a clinically significant increase in serum Euphyllin (Theophylline) concentrations. Children with rapid rates of Euphyllin (Theophylline) clearance (i.e., those who require a dose that is substantially larger than average [e.g., >22 mg/kg/day] to achieve a therapeutic peak serum Euphyllin (Theophylline) concentration when afebrile) may be at greater risk of toxic effects from decreased clearance during sustained fever. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in patients with sustained fever (see WARNINGS ).

Miscellaneous

Other factors associated with decreased Euphyllin (Theophylline) clearance include the third trimester of pregnancy, sepsis with multiple organ failure, and hypothyroidism. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in patients with any of these conditions (see WARNINGS ). Other factors associated with increased Euphyllin (Theophylline) clearance include hyperthyroidism and cystic fibrosis.

CLINICAL STUDIES

In patients with chronic asthma, including patients with severe asthma requiring inhaled corticosteroids or alternate-day oral corticosteroids, many clinical studies have shown that Euphyllin (Theophylline) decreases the frequency and severity of symptoms, including nocturnal exacerbations, and decreases the “as needed” use of inhaled beta-2 agonists. Euphyllin (Theophylline) has also been shown to reduce the need for short courses of daily oral prednisone to relieve exacerbations of airway obstruction that are unresponsive to bronchodilators in asthmatics.

In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that Euphyllin (Theophylline) decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements.

INDICATIONS AND USAGE

Euphyllin (Theophylline) is indicated for the treatment of the symptoms and reversible airflow obstruction associated with chronic asthma and other chronic lung diseases, e.g., emphysema and chronic bronchitis.

CONTRAINDICATIONS

Euphyllin (Theophylline)® is contraindicated in patients with a history of hypersensitivity to Euphyllin (Theophylline) or other components in the product.

WARNINGS

Concurrent Illness

Euphyllin should be used with extreme caution in patients with the following clinical conditions due to the increased risk of exacerbation of the concurrent condition:

Active peptic ulcer disease

Seizure disorders

Cardiac arrhythmias (not including bradyarrhythmias)

Conditions That Reduce Euphyllin (Theophylline) Clearance

There are several readily identifiable causes of reduced Euphyllin (Theophylline) clearance. If the total daily dose is not appropriately reduced in the presence of these risk factors, severe and potentially fatal Euphyllin (Theophylline) toxicity can occur . Careful consideration must be given to the benefits and risks of Euphyllin (Theophylline) use and the need for more intensive monitoring of serum Euphyllin (Theophylline) concentrations in patients with the following risk factors:

Age

  • Neonates (term and premature)
  • Children <1 year
  • Elderly (>60 years)

Concurrent Diseases

  • Acute pulmonary edema
  • Congestive heart failure
  • Cor-pulmonale
  • Fever; ≥102° for 24 hours or more; or lesser temperature elevations for longer periods
  • Hypothyroidism
  • Liver disease; cirrhosis, acute hepatitis
  • Reduced renal function in infants <3 months of age
  • Sepsis with multi-organ failure
  • Shock

Cessation of Smoking

Drug Interactions

Adding a drug that inhibits Euphyllin metabolism (e.g., cimetidine, erythromycin, tacrine) or stopping a concurrently administered drug that enhances Euphyllin (Theophylline) metabolism (e.g., carbamazepine, rifampin). (see PRECAUTIONS, Drug Interactions, Table II ).

When Signs or Symptoms of Euphyllin (Theophylline) Toxicity Are Present

Whenever a patient receiving Euphyllin (Theophylline) develops nausea or vomiting, particularly repetitive vomiting, or other signs or symptoms consistent with Euphyllin (Theophylline) toxicity (even if another cause may be suspected), additional doses of Euphyllin (Theophylline) should be withheld and a serum Euphyllin (Theophylline) concentration measured immediately . Patients should be instructed not to continue any dosage that causes adverse effects and to withhold subsequent doses until the symptoms have resolved, at which time the healthcare professional may instruct the patient to resume the drug at a lower dosage (see DOSAGE AND ADMINISTRATION, Dosing Guidelines, Table VI ).

Dosage Increases

Increases in the dose of Euphyllin (Theophylline) should not be made in response to an acute exacerbation of symptoms of chronic lung disease since Euphyllin (Theophylline) provides little added benefit to inhaled beta2-selective agonists and systemically administered corticosteroids in this circumstance and increases the risk of adverse effects. A peak steady-state serum Euphyllin (Theophylline) concentration should be measured before increasing the dose in response to persistent chronic symptoms to ascertain whether an increase in dose is safe. Before increasing the Euphyllin (Theophylline) dose on the basis of a low serum concentration, the healthcare professional should consider whether the blood sample was obtained at an appropriate time in relationship to the dose and whether the patient has adhered to the prescribed regimen (see PRECAUTIONS, Laboratory Tests ).

As the rate of Euphyllin (Theophylline) clearance may be dose-dependent (i.e., steady-state serum concentrations may increase disproportionately to the increase in dose), an increase in dose based upon a sub-therapeutic serum concentration measurement should be conservative. In general, limiting dose increases to about 25% of the previous total daily dose will reduce the risk of unintended excessive increases in serum Euphyllin (Theophylline) concentration (see DOSAGE AND ADMINISTRATION, Table VI ).

PRECAUTIONS

General

Careful consideration of the various interacting drugs and physiologic conditions that can alter Euphyllin clearance and require dosage adjustment should occur prior to initiation of Euphyllin (Theophylline) therapy, prior to increases in Euphyllin (Theophylline) dose, and during follow up (see WARNINGS ). The dose of Euphyllin (Theophylline) selected for initiation of therapy should be low and, if tolerated , increased slowly over a period of a week or longer with the final dose guided by monitoring serum Euphyllin (Theophylline) concentrations and the patient’s clinical response (see DOSAGE AND ADMINISTRATION , Table V).

Monitoring Serum Euphyllin (Theophylline) Concentrations

Serum Euphyllin (Theophylline) concentration measurements are readily available and should be used to determine whether the dosage is appropriate. Specifically, the serum Euphyllin (Theophylline) concentration should be measured as follows:

  • When initiating therapy to guide final dosage adjustment after titration.
  • Before making a dose increase to determine whether the serum concentration is sub-therapeutic in a patient who continues to be symptomatic.
  • Whenever signs or symptoms of Euphyllin (Theophylline) toxicity are present.
  • Whenever there is a new illness, worsening of a chronic illness or a change in the patient’s treatment regimen that may alter Euphyllin (Theophylline) clearance (e.g., fever >102°F sustained for ≥24 hours, hepatitis, or drugs listed in Table II are added or discontinued).

To guide a dose increase, the blood sample should be obtained at the time of the expected peak serum Euphyllin (Theophylline) concentration; 12 hours after an evening dose or 9 hours after a morning dose at steady-state. For most patients, steady-state will be reached after 3 days of dosing when no doses have been missed, no extra doses have been added, and none of the doses have been taken at unequal intervals. A trough concentration (i.e., at the end of the dosing interval) provides no additional useful information and may lead to an inappropriate dose increase since the peak serum Euphyllin (Theophylline) concentration can be two or more times greater than the trough concentration with an immediate-release formulation. If the serum sample is drawn more than 12 hours after the evening dose, or more than 9 hours after a morning dose, the results must be interpreted with caution since the concentration may not be reflective of the peak concentration. In contrast, when signs or symptoms of Euphyllin (Theophylline) toxicity are present, a serum sample should be obtained as soon as possible, analyzed immediately, and the result reported to the healthcare professional without delay. In patients in whom decreased serum protein binding is suspected (e.g., cirrhosis, women during the third trimester of pregnancy), the concentration of unbound Euphyllin (Theophylline) should be measured and the dosage adjusted to achieve an unbound concentration of 6-12 mcg/mL.

Saliva concentrations of Euphyllin (Theophylline) cannot be used reliably to adjust dosage without special techniques.

Effects on Laboratory Tests

As a result of its pharmacological effects, Euphyllin at serum concentrations within the 10-20 mcg/mL range modestly increases plasma glucose (from a mean of 88 mg% to 98 mg%), uric acid (from a mean of 4 mg/dL to 6 mg/dL), free fatty acids (from a mean of 451 µEq/L to 800 µEq/L, total cholesterol (from a mean of 140 vs 160 mg/dL), HDL (from a mean of 36 to 50 mg/dL), HDL/LDL ratio (from a mean of 0.5 to 0.7), and urinary free cortisol excretion (from a mean of 44 to 63 mcg/24 hr). Euphyllin (Theophylline) at serum concentrations within the 10-20 mcg/mL range may also transiently decrease serum concentrations of triiodothyronine (144 before, 131 after one week and 142 ng/dL after 4 weeks of Euphyllin (Theophylline)). The clinical importance of these changes should be weighed against the potential therapeutic benefit of Euphyllin (Theophylline) in individual patients.

Information for Patients

The patient (or parent/caregiver) should be instructed to seek medical advice whenever nausea, vomiting, persistent headache, insomnia or rapid heartbeat occurs during treatment with Euphyllin (Theophylline), even if another cause is suspected. The patient should be instructed to contact their healthcare professional if they develop a new illness, especially if accompanied by a persistent fever, if they experience worsening of a chronic illness, if they start or stop smoking cigarettes or marijuana, or if another healthcare professional adds a new medication or discontinues a previously prescribed medication. Patients should be informed that Euphyllin (Theophylline) interacts with a wide variety of drugs. The dietary supplement St. John’s Wort (Hypericum perforatum) should not be taken at the same time as Euphyllin (Theophylline), since it may result in decreased Euphyllin (Theophylline) levels. If patients are already taking St. John’s Wort and Euphyllin (Theophylline) together, they should consult their healthcare professional before stopping the St. John’s Wort, since their Euphyllin (Theophylline) concentrations may rise when this is done, resulting in toxicity. Patients should be instructed to inform all healthcare professionals involved in their care that they are taking Euphyllin (Theophylline), especially when a medication is being added or deleted from their treatment. Patients should be instructed to not alter the dose, timing of the dose, or frequency of administration without first consulting their healthcare professional. If a dose is missed, the patient should be instructed to take the next dose at the usually scheduled time and to not attempt to make up for the missed dose.

Euphyllin (Theophylline)® Tablets can be taken once a day in the morning or evening. It is recommended that Euphyllin (Theophylline) be taken with meals. Patients should be advised that if they choose to take Euphyllin (Theophylline) with food it should be taken consistently with food and if they take it in a fasted condition it should routinely be taken fasted. It is important that the product whenever dosed be dosed consistently with or without food.

Euphyllin (Theophylline) Tablets are not to be chewed or crushed because it may lead to a rapid release of Euphyllin (Theophylline) with the potential for toxicity. The scored tablet may be split. Patients receiving Euphyllin (Theophylline) Tablets may pass an intact matrix tablet in the stool or via colostomy. These matrix tablets usually contain little or no residual Euphyllin (Theophylline).

Drug Interactions

Euphyllin interacts with a wide variety of drugs. The interaction may be pharmacodynamic, i.e., alterations in the therapeutic response to Euphyllin (Theophylline) or another drug or occurrence of adverse effects without a change in serum Euphyllin (Theophylline) concentration. More frequently, however, the interaction is pharmacokinetic, i.e., the rate of Euphyllin (Theophylline) clearance is altered by another drug resulting in increased or decreased serum Euphyllin (Theophylline) concentrations. Euphyllin (Theophylline) only rarely alters the pharmacokinetics of other drugs.

The drugs listed in Table II have the potential to produce clinically significant pharmacodynamic or pharmacokinetic interactions with Euphyllin (Theophylline). The information in the “Effect” column of Table II assumes that the interacting drug is being added to a steady-state Euphyllin (Theophylline) regimen. If Euphyllin (Theophylline) is being initiated in a patient who is already taking a drug that inhibits Euphyllin (Theophylline) clearance (e.g., cimetidine, erythromycin), the dose of Euphyllin (Theophylline) required to achieve a therapeutic serum Euphyllin (Theophylline) concentration will be smaller. Conversely, if Euphyllin (Theophylline) is being initiated in a patient who is already taking a drug that enhances Euphyllin (Theophylline) clearance (e.g., rifampin), the dose of Euphyllin (Theophylline) required to achieve a therapeutic serum Euphyllin (Theophylline) concentration will be larger. Discontinuation of a concomitant drug that increases Euphyllin (Theophylline) clearance will result in accumulation of Euphyllin (Theophylline) to potentially toxic levels, unless the Euphyllin (Theophylline) dose is appropriately reduced. Discontinuation of a concomitant drug that inhibits Euphyllin (Theophylline) clearance will result in decreased serum Euphyllin (Theophylline) concentrations, unless the Euphyllin (Theophylline) dose is appropriately increased.

The drugs listed in Table III have either been documented not to interact with Euphyllin (Theophylline) or do not produce a clinically significant interaction (i.e., <15% change in Euphyllin (Theophylline) clearance).

The listing of drugs in Tables II and III are current as of February 9, 1995. New interactions are continuously being reported for Euphyllin (Theophylline), especially with new chemical entities. The healthcare professional should not assume that a drug does not interact with Euphyllin (Theophylline) if it is not listed in Table II. Before addition of a newly available drug in a patient receiving Euphyllin (Theophylline), the package insert of the new drug and/or the medical literature should be consulted to determine if an interaction between the new drug and Euphyllin (Theophylline) has been reported.

Drug Type of Interaction Effect**
*Refer to PRECAUTIONS, Drug Interactions for further information regarding table.
**Average effect on steady-state Euphyllin (Theophylline) concentration or other clinical effect for pharmacologic interactions. Individual patients may experience larger changes in serum Euphyllin (Theophylline) concentration than the value listed.
Adenosine Euphyllin (Theophylline) blocks adenosine receptors. Higher doses of adenosine may be required to achieve desired effect.
Alcohol A single large dose of alcohol (3 mL/kg of whiskey) decreases Euphyllin (Theophylline) clearance for up to 24 hours. 30% increase
Allopurinol Decreases Euphyllin (Theophylline) clearance at allopurinol doses ≥600 mg/day. 25% increase
Aminoglutethimide Increases Euphyllin (Theophylline) clearance by induction of microsomal enzyme activity. 25% decrease
Carbamazepine Similar to aminoglutethimide. 30% decrease
Cimetidine Decreases Euphyllin (Theophylline) clearance by inhibiting cytochrome P450 1A2. 70% increase
Ciprofloxacin Similar to cimetidine. 40% increase
Clarithromycin Similar to erythromycin. 25% increase
Diazepam Benzodiazepines increase CNS concentrations of adenosine, a potent CNS depressant, while Euphyllin (Theophylline) blocks adenosine receptors. Larger diazepam doses may be required to produce desired level of sedation. Discontinuation of Euphyllin (Theophylline) without reduction of diazepam dose may result in respiratory depression.
Disulfiram Decreases Euphyllin (Theophylline) clearance by inhibiting hydroxylation and demethylation. 50% increase
Enoxacin Similar to cimetidine. 300% increase
Ephedrine Synergistic CNS effects. Increased frequency of nausea, nervousness, and insomnia.
Erythromycin Erythromycin metabolite decreases Euphyllin (Theophylline) clearance by inhibiting cytochrome P450 3A3. 35% increase. Erythromycin steady-state serum concentrations decrease by a similar amount.
Estrogen Estrogen containing oral contraceptives decrease Euphyllin (Theophylline) clearance in a dose-dependent fashion. The effect of progesterone on Euphyllin (Theophylline) clearance is unknown. 30% increase
Flurazepam Similar to diazepam. Similar to diazepam.
Fluvoxamine Similar to cimetidine. Similar to cimetidine.
Halothane Halothane sensitizes the myocardium to catecholamines, Euphyllin (Theophylline) increases release of endogenous catecholamines. Increased risk of ventricular arrhythmias.
Interferon, human recombinant alpha-A Decreases Euphyllin (Theophylline) clearance. 100% increase
Isoproterenol (IV) Increases Euphyllin (Theophylline) clearance. 20% decrease
Ketamine Pharmacologic May lower Euphyllin (Theophylline) seizure threshold.
Lithium Euphyllin (Theophylline) increases renal lithium clearance. Lithium dose required to achieve a therapeutic serum concentration increased an average of 60%.
Lorazepam Similar to diazepam. Similar to diazepam.
Methotrexate (MTX) Decreases Euphyllin (Theophylline) clearance. 20% increase after low dose MTX, higher dose MTX may have a greater effect.
Mexiletine Similar to disulfiram. 80% increase
Midazolam Similar to diazepam. Similar to diazepam.
Moricizine Increases Euphyllin (Theophylline) clearance. 25% decrease
Pancuronium Euphyllin (Theophylline) may antagonize non-depolarizing neuromuscular blocking effects; possibly due to phosphodiesterase inhibition. Larger dose of pancuronium may be required to achieve neuromuscular blockade.
Pentoxifylline Decreases Euphyllin (Theophylline) clearance. 30% increase
Phenobarbital (PB) Similar to aminoglutethimide. 25% decrease after two weeks of concurrent PB.
Phenytoin Phenytoin increases Euphyllin (Theophylline) clearance by increasing microsomal enzyme activity. Euphyllin (Theophylline) decreases phenytoin absorption. Serum Euphyllin (Theophylline) and phenytoin concentrations decrease about 40%.
Propafenone Decreases Euphyllin (Theophylline) clearance and pharmacologic interaction. 40% increase. Beta-2 blocking effect may decrease efficacy of Euphyllin (Theophylline).
Propranolol Similar to cimetidine and pharmacologic interaction. 100% increase. Beta-2 blocking effect may decrease efficacy of Euphyllin (Theophylline).
Rifampin Increases Euphyllin (Theophylline) clearance by increasing cytochrome P450 1A2 and 3A3 activity. 20-40% decrease
St. John’s Wort (Hypericum Perforatum) Decrease in Euphyllin (Theophylline) plasma concentrations. Higher doses of Euphyllin (Theophylline) may be required to achieve desired effect. Stopping St. John’s Wort may result in Euphyllin (Theophylline) toxicity.
Sulfinpyrazone Increases Euphyllin (Theophylline) clearance by increasing demethylation and hydroxylation. Decreases renal clearance of Euphyllin (Theophylline). 20% decrease
Tacrine Similar to cimetidine, also increases renal clearance of Euphyllin (Theophylline). 90% increase
Thiabendazole Decreases Euphyllin (Theophylline) clearance. 190% increase
Ticlopidine Decreases Euphyllin (Theophylline) clearance. 60% increase
Troleandomycin Similar to erythromycin. 33-100% increase depending on troleandomycin dose.
Verapamil Similar to disulfiram. 20% increase
*Refer to PRECAUTIONS, Drug Interactions for information regarding table.
albuterol, systemic and inhaled mebendazole
amoxicillin medroxyprogesterone
ampicillin, with or without

sulbactam

methylprednisolone

metronidazole

atenolol metoprolol
azithromycin nadolol
caffeine, dietary ingestion nifedipine
cefaclor nizatidine
co-trimoxazole (trimethoprim and

sulfamethoxazole)

norfloxacin

ofloxacin

diltiazem omeprazole
dirithromycin prednisone, prednisolone
enflurane ranitidine
famotidine rifabutin
felodipine roxithromycin
finasteride sorbitol (purgative doses do not inhibit
hydrocortisone Euphyllin (Theophylline) absorption)
isoflurane sucralfate
isoniazid terbutaline, systemic
isradipine terfenadine
influenza vaccine tetracycline
ketoconazole tocainide
lomefloxacin

Drug-Food Interactions

The bioavailability of Euphyllin (Theophylline)® Tablets (theophylline, anhydrous) has been studied with co-administration of food. In three single-dose studies, subjects given Euphyllin (Theophylline) 400 mg or 600 mg Tablets with a standardized high-fat meal were compared to fasted conditions. Under fed conditions, the peak plasma concentration and bioavailability were increased; however, a precipitous increase in the rate and extent of absorption was not evident (see Pharmacokinetics , Absorption). The increased peak and extent of absorption under fed conditions suggests that dosing should be ideally administered consistently either with or without food.

The Effect of Other Drugs on Euphyllin Serum Concentration Measurements

Most serum Euphyllin (Theophylline) assays in clinical use are immunoassays which are specific for Euphyllin (Theophylline). Other xanthines such as caffeine, dyphylline, and pentoxifylline are not detected by these assays. Some drugs (e.g., cefazolin, cephalothin), however, may interfere with certain HPLC techniques. Caffeine and xanthine metabolites in neonates or patients with renal dysfunction may cause the reading from some dry reagent office methods to be higher than the actual serum Euphyllin (Theophylline) concentration.

Carcinogenesis, Mutagenesis, and Impairment of Fertility

Long term carcinogenicity studies have been carried out in mice and rats (oral doses 5-75 mg/kg). Results are pending.

Euphyllin (Theophylline) has been studied in Ames salmonella, in vivo and in vitro cytogenetics, micronucleus and Chinese hamster ovary test systems and has not been shown to be genotoxic.

In a 14 week continuous breeding study, Euphyllin (Theophylline), administered to mating pairs of B6C3F1 mice at oral doses of 120, 270 and 500 mg/kg (approximately 1.0-3.0 times the human dose on a mg/m2 basis) impaired fertility, as evidenced by decreases in the number of live pups per litter, decreases in the mean number of litters per fertile pair, and increases in the gestation period at the high dose as well as decreases in the proportion of pups born alive at the mid and high dose. In 13 week toxicity studies, Euphyllin (Theophylline) was administered to F344 rats and B6C3F1 mice at oral doses of 40-300 mg/kg (approximately 2.0 times the human dose on a mg/m2 basis). At the high dose, systemic toxicity was observed in both species including decreases in testicular weight.

Pregnancy: Teratogenic Effects: Category C

In studies in which pregnant mice, rats and rabbits were dosed during the period of organogenesis, Euphyllin (Theophylline) produced teratogenic effects.

In studies with mice, a single intraperitoneal dose at and above 100 mg/kg (approximately equal to the maximum recommended oral dose for adults on a mg/m2 basis) during organogenesis produced cleft palate and digital abnormalities. Micromelia, micrognathia, clubfoot, subcutaneous hematoma, open eyelids, and embryolethality were observed at doses that are approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis.

In a study with rats dosed from conception through organogenesis, an oral dose of 150 mg/kg/day (approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis) produced digital abnormalities. Embryolethality was observed with a subcutaneous dose of 200 mg/kg/day (approximately 4 times the maximum recommended oral dose for adults on a mg/m2 basis).

In a study in which pregnant rabbits were dosed throughout organogenesis, an intravenous dose of 60 mg/kg/day (approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis), which caused the death of one doe and clinical signs in others, produced cleft palate and was embryolethal. Doses at and above 15 mg/kg/day (less than the maximum recommended oral dose for adults on a mg/m2 basis) increased the incidence of skeletal variations.

There are no adequate and well-controlled studies in pregnant women. Euphyllin (Theophylline) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers

Euphyllin is excreted into breast milk and may cause irritability or other signs of mild toxicity in nursing human infants. The concentration of Euphyllin (Theophylline) in breast milk is about equivalent to the maternal serum concentration. An infant ingesting a liter of breast milk containing 10-20 mcg/mL of Euphyllin (Theophylline) per day is likely to receive 10-20 mg of Euphyllin (Theophylline) per day. Serious adverse effects in the infant are unlikely unless the mother has toxic serum Euphyllin (Theophylline) concentrations.

Pediatric Use

Euphyllin (Theophylline) is safe and effective for the approved indications in pediatric patients. The maintenance dose of Euphyllin (Theophylline) must be selected with caution in pediatric patients since the rate of Euphyllin (Theophylline) clearance is highly variable across the pediatric age range (see CLINICAL PHARMACOLOGY, Table I, WARNINGS, and DOSAGE AND ADMINISTRATION, Table V ).

Geriatric Use

Elderly patients are at a significantly greater risk of experiencing serious toxicity from Euphyllin (Theophylline) than younger patients due to pharmacokinetic and pharmacodynamic changes associated with aging. The clearance of Euphyllin (Theophylline) is decreased by an average of 30% in healthy elderly adults (>60 yrs) compared to healthy young adults. Euphyllin (Theophylline) clearance may be further reduced by concomitant diseases prevalent in the elderly, which further impair clearance of this drug and have the potential to increase serum levels and potential toxicity. These conditions include impaired renal function, chronic obstructive pulmonary disease, congestive heart failure, hepatic disease and an increased prevalence of use of certain medications (see PRECAUTIONS: Drug Interactions ) with the potential for pharmacokinetic and pharmacodynamic interaction. Protein binding may be decreased in the elderly resulting in an increased proportion of the total serum Euphyllin (Theophylline) concentration in the pharmacologically active unbound form. Elderly patients also appear to be more sensitive to the toxic effects of Euphyllin (Theophylline) after chronic overdosage than younger patients. Careful attention to dose reduction and frequent monitoring of serum Euphyllin (Theophylline) concentrations are required in elderly patients (see PRECAUTIONS, Monitoring Serum Euphyllin (Theophylline) Concentrations, and DOSAGE AND ADMINISTRATION ). The maximum daily dose of Euphyllin (Theophylline) in patients greater than 60 years of age ordinarily should not exceed 400 mg/day unless the patient continues to be symptomatic and the peak steady-state serum Euphyllin (Theophylline) concentration is <10 mcg/mL (see DOSAGE AND ADMINISTRATION ). Euphyllin (Theophylline) doses greater than 400 mg/d should be prescribed with caution in elderly patients. Euphyllin (Theophylline) should be prescribed with caution in elderly male patients with pre-existing partial outflow obstruction, such as prostatic enlargement, due to the risk of urinary retention.

ADVERSE REACTIONS

Adverse reactions associated with Euphyllin (Theophylline) are generally mild when peak serum Euphyllin (Theophylline) concentrations are <20 mcg/mL and mainly consist of transient caffeine-like adverse effects such as nausea, vomiting, headache, and insomnia. When peak serum Euphyllin (Theophylline) concentrations exceed 20 mcg/mL, however, Euphyllin (Theophylline) produces a wide range of adverse reactions including persistent vomiting, cardiac arrhythmias, and intractable seizures which can be lethal (see OVERDOSAGE ). The transient caffeine-like adverse reactions occur in about 50% of patients when Euphyllin (Theophylline) therapy is initiated at doses higher than recommended initial doses (e.g., >300 mg/day in adults and >12 mg/kg/day in children beyond >1 year of age). During the initiation of Euphyllin (Theophylline) therapy, caffeine-like adverse effects may transiently alter patient behavior, especially in school age children, but this response rarely persists. Initiation of Euphyllin (Theophylline) therapy at a low dose with subsequent slow titration to a predetermined age-related maximum dose will significantly reduce the frequency of these transient adverse effects (see DOSAGE AND ADMINISTRATION, Table V ). In a small percentage of patients (<3% of children and <10% of adults) the caffeine-like adverse effects persist during maintenance therapy, even at peak serum Euphyllin (Theophylline) concentrations within the therapeutic range (i.e., 10-20 mcg/mL). Dosage reduction may alleviate the caffeine-like adverse effects in these patients, however, persistent adverse effects should result in a reevaluation of the need for continued Euphyllin (Theophylline) therapy and the potential therapeutic benefit of alternative treatment.

Other adverse reactions that have been reported at serum Euphyllin (Theophylline) concentrations <20 mcg/mL include abdominal pain, agitation, anaphylactic reaction, anaphylactoid reaction, anxiety, cardiac arrhythmias, diarrhea, dizziness, fine skeletal muscle tremors, gastric irritation, gastroesophageal reflux, hyperuricemia, irritability, palpitations, pruritus, rash, sinus tachycardia, restlessness, transient diuresis, urinary retention and urticaria. In patients with hypoxia secondary to COPD, multifocal atrial tachycardia and flutter have been reported at serum Euphyllin (Theophylline) concentrations ≥15 mcg/mL. There have been a few isolated reports of seizures at serum Euphyllin (Theophylline) concentrations <20 mcg/mL in patients with an underlying neurological disease or in elderly patients. The occurrence of seizures in elderly patients with serum Euphyllin (Theophylline) concentrations <20 mcg/mL may be secondary to decreased protein binding resulting in a larger proportion of the total serum Euphyllin (Theophylline) concentration in the pharmacologically active unbound form. The clinical characteristics of the seizures reported in patients with serum Euphyllin (Theophylline) concentrations <20 mcg/mL have generally been milder than seizures associated with excessive serum Euphyllin (Theophylline) concentrations resulting from an overdose (i.e., they have generally been transient, often stopped without anticonvulsant therapy, and did not result in neurological residua).

Percentage of patients reported with sign or symptom
Sign/Symptom Acute Overdose Chronic Overdosage
(Large Single Ingestion) (Multiple Excessive Doses)
Study 1 Study 2 Study 1 Study 2
(n=157) (n=14) (n=92) (n=102)
*These data are derived from two studies in patients with serum Euphyllin (Theophylline) concentrations >30 mcg/mL. In the first study (Study #1-Shanon, Ann Intern Med 1993;119:1161-67), data were prospectively collected from 249 consecutive cases of Euphyllin (Theophylline) toxicity referred to a regional poison center for consultation. In the second study (Study #2-Sessler, Am J Med 1990;88:567-76), data were retrospectively collected from 116 cases with serum Euphyllin (Theophylline) concentrations >30 mcg/mL among 6000 blood samples obtained for measurement of serum Euphyllin (Theophylline) concentrations in three emergency departments. Differences in the incidence of manifestations of Euphyllin (Theophylline) toxicity between the two studies may reflect sample selection as a result of study design (e.g., in Study #1, 48% of the patients had acute intoxications versus only 10% in Study #2) and different methods of reporting results.
**NR=Not reported in a comparable manner.
Asymptomatic NR** 0 NR** 6
Gastrointestinal
Vomiting 73 93 30 61
Abdominal Pain NR** 21 NR** 12
Diarrhea NR** 0 NR** 14
Hematemesis NR** 0 NR** 2
Metabolic/Other
Hypokalemia 85 79 44 43
Hyperglycemia 98 NR** 18 NR**
Acid/base disturbance 34 21 9 5
Rhabdomyolysis NR** 7 NR** 0
Cardiovascular
Sinus tachycardia 100 86 100 62
Other supraventricular
tachycardias 2 21 12 14
Ventricular premature beats 3 21 10 19
Atrial fibrillation or flutter 1 NR** 12 NR**
Multifocal atrial tachycardia 0 NR** 2 NR**
Ventricular arrhythmias with

hemodynamic instability

7 14 40 0
Hypotension/shock NR** 21 NR** 8
Neurologic
Nervousness NR** 64 NR** 21
Tremors 38 29 16 14
Disorientation NR** 7 NR** 11
Seizures 5 14 14 5
Death 3 21 10 4

OVERDOSAGE

General

The chronicity and pattern of Euphyllin overdosage significantly influences clinical manifestations of toxicity, management and outcome. There are two common presentations: (1) acute overdose, i.e., ingestion of a single large excessive dose (>10 mg/kg), as occurs in the context of an attempted suicide or isolated medication error, and (2) chronic overdosage, i.e., ingestion of repeated doses that are excessive for the patient’s rate of Euphyllin (Theophylline) clearance. The most common causes of chronic Euphyllin (Theophylline) overdosage include patient or caregiver error in dosing, healthcare professional prescribing of an excessive dose or a normal dose in the presence of factors known to decrease the rate of Euphyllin (Theophylline) clearance, and increasing the dose in response to an exacerbation of symptoms without first measuring the serum Euphyllin (Theophylline) concentration to determine whether a dose increase is safe.

Severe toxicity from Euphyllin (Theophylline) overdose is a relatively rare event. In one health maintenance organization, the frequency of hospital admissions for chronic overdosage of Euphyllin (Theophylline) was about 1 per 1000 person-years exposure. In another study, among 6000 blood samples obtained for measurement of serum Euphyllin (Theophylline) concentration, for any reason, from patients treated in an emergency department, 7% were in the 20-30 mcg/mL range and 3% were >30 mcg/mL. Approximately two-thirds of the patients with serum Euphyllin (Theophylline) concentrations in the 20-30 mcg/mL range had one or more manifestations of toxicity while >90% of patients with serum Euphyllin (Theophylline) concentrations >30 mcg/mL were clinically intoxicated. Similarly, in other reports, serious toxicity from Euphyllin (Theophylline) is seen principally at serum concentrations >30 mcg/mL.

Several studies have described the clinical manifestations of Euphyllin (Theophylline) overdose and attempted to determine the factors that predict life-threatening toxicity. In general, patients who experience an acute overdose are less likely to experience seizures than patients who have experienced a chronic overdosage, unless the peak serum Euphyllin (Theophylline) concentration is >100 mcg/mL. After a chronic overdosage, generalized seizures, life-threatening cardiac arrhythmias, and death may occur at serum Euphyllin (Theophylline) concentrations >30 mcg/mL. The severity of toxicity after chronic overdosage is more strongly correlated with the patient’s age than the peak serum Euphyllin (Theophylline) concentration; patients >60 years are at the greatest risk for severe toxicity and mortality after a chronic overdosage. Pre-existing or concurrent disease may also significantly increase the susceptibility of a patient to a particular toxic manifestation, e.g., patients with neurologic disorders have an increased risk of seizures and patients with cardiac disease have an increased risk of cardiac arrhythmias for a given serum Euphyllin (Theophylline) concentration compared to patients without the underlying disease.

The frequency of various reported manifestations of Euphyllin (Theophylline) overdose according to the mode of overdose are listed in Table IV.

Other manifestations of Euphyllin (Theophylline) toxicity include increases in serum calcium, creatine kinase, myoglobin and leukocyte count, decreases in serum phosphate and magnesium, acute myocardial infarction, and urinary retention in men with obstructive uropathy.

Seizures associated with serum Euphyllin (Theophylline) concentrations >30 mcg/mL are often resistant to anticonvulsant therapy and may result in irreversible brain injury if not rapidly controlled. Death from Euphyllin (Theophylline) toxicity is most often secondary to cardiorespiratory arrest and/or hypoxic encephalopathy following prolonged generalized seizures or intractable cardiac arrhythmias causing hemodynamic compromise.

Overdose Management

General Recommendations for Patients with Symptoms of Euphyllin (Theophylline) Overdose or Serum Euphyllin (Theophylline) Concentrations >30 mcg/mL (Note: Serum Euphyllin (Theophylline) concentrations may continue to increase after presentation of the patient for medical care.)

  • While simultaneously instituting treatment, contact a regional poison center to obtain updated information and advice on individualizing the recommendations that follow.
  • Institute supportive care, including establishment of intravenous access, maintenance of the airway, and electrocardiographic monitoring.
  • Treatment of seizures Because of the high morbidity and mortality associated with theophylline-induced seizures, treatment should be rapid and aggressive. Anticonvulsant therapy should be initiated with an intravenous benzodiazepine, e.g., diazepam, in increments of 0.1-0.2 mg/kg every 1-3 minutes until seizures are terminated. Repetitive seizures should be treated with a loading dose of phenobarbital (20 mg/kg infused over 30-60 minutes). Case reports of Euphyllin (Theophylline) overdose in humans and animal studies suggest that phenytoin is ineffective in terminating theophylline-induced seizures. The doses of benzodiazepines and phenobarbital required to terminate theophylline-induced seizures are close to the doses that may cause severe respiratory depression or respiratory arrest; the healthcare professional should therefore be prepared to provide assisted ventilation. Elderly patients and patients with COPD may be more susceptible to the respiratory depressant effects of anticonvulsants. Barbiturate-induced coma or administration of general anesthesia may be required to terminate repetitive seizures or status epilepticus. General anesthesia should be used with caution in patients with Euphyllin (Theophylline) overdose because fluorinated volatile anesthetics may sensitize the myocardium to endogenous catecholamines released by Euphyllin (Theophylline). Enflurane appears less likely to be associated with this effect than halothane and may, therefore, be safer. Neuromuscular blocking agents alone should not be used to terminate seizures since they abolish the musculoskeletal manifestations without terminating seizure activity in the brain.
  • Anticipate Need for Anticonvulsants In patients with Euphyllin (Theophylline) overdose who are at high risk for theophylline-induced seizures, e.g., patients with acute overdoses and serum Euphyllin (Theophylline) concentrations >100 mcg/mL or chronic overdosage in patients >60 years of age with serum Euphyllin (Theophylline) concentrations >30 mcg/mL, the need for anticonvulsant therapy should be anticipated. A benzodiazepine such as diazepam should be drawn into a syringe and kept at the patient’s bedside and medical personnel qualified to treat seizures should be immediately available. In selected patients at high risk for theophylline-induced seizures, consideration should be given to the administration of prophylactic anticonvulsant therapy. Situations where prophylactic anticonvulsant therapy should be considered in high risk patients include anticipated delays in instituting methods for extracorporeal removal of Euphyllin (Theophylline) (e.g., transfer of a high risk patient from one healthcare facility to another for extracorporeal removal) and clinical circumstances that significantly interfere with efforts to enhance Euphyllin (Theophylline) clearance (e.g., a neonate where dialysis may not be technically feasible or a patient with vomiting unresponsive to antiemetics who is unable to tolerate multiple-dose oral activated charcoal). In animal studies, prophylactic administration of phenobarbital, but not phenytoin, has been shown to delay the onset of theophylline-induced generalized seizures and to increase the dose of Euphyllin (Theophylline) required to induce seizures (i.e., markedly increases the LD50). Although there are no controlled studies in humans, a loading dose of intravenous phenobarbital (20 mg/kg infused over 60 minutes) may delay or prevent life-threatening seizures in high risk patients while efforts to enhance Euphyllin (Theophylline) clearance are continued. Phenobarbital may cause respiratory depression, particularly in elderly patients and patients with COPD.
  • Treatment of cardiac arrhythmias Sinus tachycardia and simple ventricular premature beats are not harbingers of life-threatening arrhythmias, they do not require treatment in the absence of hemodynamic compromise, and they resolve with declining serum Euphyllin (Theophylline) concentrations. Other arrhythmias, especially those associated with hemodynamic compromise, should be treated with antiarrhythmic therapy appropriate for the type of arrhythmia.
  • Gastrointestinal decontamination Oral activated charcoal (0.5 g/kg up to 20 g and repeat at least once 1-2 hours after the first dose) is extremely effective in blocking the absorption of Euphyllin (Theophylline) throughout the gastrointestinal tract, even when administered several hours after ingestion. If the patient is vomiting, the charcoal should be administered through a nasogastric tube or after administration of an antiemetic. Phenothiazine antiemetics such as prochlorperazine or perphenazine should be avoided since they can lower the seizure threshold and frequently cause dystonic reactions. A single dose of sorbitol may be used to promote stooling to facilitate removal of Euphyllin (Theophylline) bound to charcoal from the gastrointestinal tract. Sorbitol, however, should be dosed with caution since it is a potent purgative which can cause profound fluid and electrolyte abnormalities, particularly after multiple doses. Commercially available fixed combinations of liquid charcoal and sorbitol should be avoided in young children and after the first dose in adolescents and adults since they do not allow for individualization of charcoal and sorbitol dosing. Ipecac syrup should be avoided in Euphyllin (Theophylline) overdoses. Although ipecac induces emesis, it does not reduce the absorption of Euphyllin (Theophylline) unless administered within 5 minutes of ingestion and even then is less effective than oral activated charcoal. Moreover, ipecac induced emesis may persist for several hours after a single dose and significantly decrease the retention and the effectiveness of oral activated charcoal.
  • Serum Euphyllin (Theophylline) Concentration Monitoring The serum Euphyllin (Theophylline) concentration should be measured immediately upon presentation, 2-4 hours later, and then at sufficient intervals, e.g., every 4 hours, to guide treatment decisions and to assess the effectiveness of therapy. Serum Euphyllin (Theophylline) concentrations may continue to increase after presentation of the patient for medical care as a result of continued absorption of Euphyllin (Theophylline) from the gastrointestinal tract. Serial monitoring of serum Euphyllin (Theophylline) serum concentrations should be continued until it is clear that the concentration is no longer rising and has returned to non-toxic levels.
  • General Monitoring Procedures Electrocardiographic monitoring should be initiated on presentation and continued until the serum Euphyllin (Theophylline) level has returned to a non-toxic level. Serum electrolytes and glucose should be measured on presentation and at appropriate intervals indicated by clinical circumstances. Fluid and electrolyte abnormalities should be promptly corrected. Monitoring and treatment should be continued until the serum concentration decreases below 20 mcg/mL.
  • Enhance clearance of Euphyllin (Theophylline) Multiple-dose oral activated charcoal (e.g., 0.5 mg/kg up to 20 g, every two hours) increases the clearance of Euphyllin (Theophylline) at least twofold by adsorption of Euphyllin (Theophylline) secreted into gastrointestinal fluids. Charcoal must be retained in, and pass through, the gastrointestinal tract to be effective; emesis should therefore be controlled by administration of appropriate antiemetics. Alternatively, the charcoal can be administered continuously through a nasogastric tube in conjunction with appropriate antiemetics. A single dose of sorbitol may be administered with the activated charcoal to promote stooling to facilitate clearance of the adsorbed Euphyllin (Theophylline) from the gastrointestinal tract. Sorbitol alone does not enhance clearance of Euphyllin (Theophylline) and should be dosed with caution to prevent excessive stooling which can result in severe fluid and electrolyte imbalances. Commercially available fixed combinations of liquid charcoal and sorbitol should be avoided in young children and after the first dose in adolescents and adults since they do not allow for individualization of charcoal and sorbitol dosing. In patients with intractable vomiting, extracorporeal methods of Euphyllin (Theophylline) removal should be instituted (see OVERDOSAGE, Extracorporeal Removal ).

Specific Recommendations

Acute Overdose

  • Serum Concentration >20<30 mcg/mL
    • Administer a single dose of oral activated charcoal.
    • Monitor the patient and obtain a serum Euphyllin concentration in 2-4 hours to insure that the concentration is not increasing.
  • Serum Concentration >30<100 mcg/mL
    • Administer multiple dose oral activated charcoal and measures to control emesis.
    • Monitor the patient and obtain serial Euphyllin (Theophylline) concentrations every 2-4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.
    • Institute extracorporeal removal if emesis, seizures, or cardiac arrhythmias cannot be adequately controlled (see OVERDOSAGE, Extracorporeal Removal ).
  • Serum Concentration>100 mcg/mL
    • Consider prophylactic anticonvulsant therapy.
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Consider extracorporeal removal, even if the patient has not experienced a seizure (see OVERDOSAGE, Extracorporeal Removal ).
    • Monitor the patient and obtain serial Euphyllin (Theophylline) concentrations every 2-4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.

Chronic Overdosage

  • Serum Concentration >20<30 mcg/mL (with manifestations of Euphyllin (Theophylline) toxicity)
    • Administer a single dose of oral activated charcoal.
    • Monitor the patient and obtain a serum Euphyllin (Theophylline) concentration in 2-4 hours to insure that the concentration is not increasing.
  • Serum Concentration >30 mcg/mL in patients <60 years of age
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Monitor the patient and obtain serial Euphyllin (Theophylline) concentrations every 2-4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.
    • Institute extracorporeal removal if emesis, seizures, or cardiac arrhythmias cannot be adequately controlled (see OVERDOSAGE, Extracorporeal Removal ).
  • Serum Concentration >30 mcg/mL in patients ≥ 60 years of age
    • Consider prophylactic anticonvulsant therapy.
    • Administer multiple-dose oral activated charcoal and measures to control emesis.
    • Consider extracorporeal removal even if the patient has not experienced a seizure.
    • Monitor the patient and obtain serial Euphyllin (Theophylline) concentrations every 2-4 hours to gauge the effectiveness of therapy and to guide further treatment decisions.

Extracorporeal Removal

Increasing the rate of Euphyllin (Theophylline) clearance by extracorporeal methods may rapidly decrease serum concentrations, but the risks of the procedure must be weighed against the potential benefit. Charcoal hemoperfusion is the most effective method of extracorporeal removal, increasing Euphyllin (Theophylline) clearance up to sixfold, but serious complications, including hypotension, hypocalcemia, platelet consumption and bleeding diatheses may occur. Hemodialysis is about as efficient as multiple-dose oral activated charcoal and has a lower risk of serious complications than charcoal hemoperfusion. Hemodialysis should be considered as an alternative when charcoal hemoperfusion is not feasible and multiple-dose oral charcoal is ineffective because of intractable emesis. Serum Euphyllin (Theophylline) concentrations may rebound 5-10 mcg/mL after discontinuation of charcoal hemoperfusion or hemodialysis due to redistribution of Euphyllin (Theophylline) from the tissue compartment. Peritoneal dialysis is ineffective for Euphyllin (Theophylline) removal; exchange transfusions in neonates have been minimally effective.

DOSAGE AND ADMINISTRATION

Euphyllin ® 400 or 600 mg Tablets can be taken once a day in the morning or evening. It is recommended that Euphyllin (Theophylline) be taken with meals. Patients should be advised that if they choose to take Euphyllin (Theophylline) with food it should be taken consistently with food and if they take it in a fasted condition it should routinely be taken fasted. It is important that the product whenever dosed be dosed consistently with or without food.

Euphyllin (Theophylline)® Tablets are not to be chewed or crushed because it may lead to a rapid release of Euphyllin (Theophylline) with the potential for toxicity. The scored tablet may be split. Infrequently, patients receiving Euphyllin (Theophylline) 400 or 600 mg Tablets may pass an intact matrix tablet in the stool or via colostomy. These matrix tablets usually contain little or no residual Euphyllin (Theophylline).

Stabilized patients, 12 years of age or older, who are taking an immediate-release or controlled-release Euphyllin (Theophylline) product may be transferred to once-daily administration of 400 mg or 600 mg Euphyllin (Theophylline) Tablets on a mg-for-mg basis.

It must be recognized that the peak and trough serum Euphyllin (Theophylline) levels produced by the once-daily dosing may vary from those produced by the previous product and/or regimen.

General Considerations

The steady-state peak serum Euphyllin (Theophylline) concentration is a function of the dose, the dosing interval, and the rate of Euphyllin (Theophylline) absorption and clearance in the individual patient. Because of marked individual differences in the rate of Euphyllin (Theophylline) clearance, the dose required to achieve a peak serum Euphyllin (Theophylline) concentration in the 10-20 mcg/mL range varies fourfold among otherwise similar patients in the absence of factors known to alter Euphyllin (Theophylline) clearance (e.g., 400-1600 mg/day in adults <60 years old and 10-36 mg/kg/day in children 1-9 years old). For a given population there is no single Euphyllin (Theophylline) dose that will provide both safe and effective serum concentrations for all patients. Administration of the median Euphyllin (Theophylline) dose required to achieve a therapeutic serum Euphyllin (Theophylline) concentration in a given population may result in either sub-therapeutic or potentially toxic serum Euphyllin (Theophylline) concentrations in individual patients. For example, at a dose of 900 mg/d in adults <60 years or 22 mg/kg/d in children 1-9 years, the steady-state peak serum Euphyllin (Theophylline) concentration will be <10 mcg/mL in about 30% of patients, 10-20 mcg/mL in about 50% and 20-30 mcg/mL in about 20% of patients. The dose of Euphyllin (Theophylline) must be individualized on the basis of peak serum Euphyllin (Theophylline) concentration measurements in order to achieve a dose that will provide maximum potential benefit with minimal risk of adverse effects.

Transient caffeine-like adverse effects and excessive serum concentrations in slow metabolizers can be avoided in most patients by starting with a sufficiently low dose and slowly increasing the dose, if judged to be clinically indicated, in small increments (see Table V ). Dose increases should only be made if the previous dosage is well tolerated and at intervals of no less than 3 days to allow serum Euphyllin (Theophylline) concentrations to reach the new steady-state. Dosage adjustment should be guided by serum Euphyllin (Theophylline) concentration measurement (see PRECAUTIONS, Laboratory Tests and DOSAGE AND ADMINISTRATION, Table VI ). Healthcare providers should instruct patients and caregivers to discontinue any dosage that causes adverse effects, to withhold the medication until these symptoms are gone and to then resume therapy at a lower, previously tolerated dosage (see WARNINGS ).

If the patient’s symptoms are well controlled, there are no apparent adverse effects, and no intervening factors that might alter dosage requirements (see WARNINGS and PRECAUTIONS ), serum Euphyllin (Theophylline) concentrations should be monitored at 6 month intervals for rapidly growing children and at yearly intervals for all others. In acutely ill patients, serum Euphyllin (Theophylline) concentrations should be monitored at frequent intervals, e.g., every 24 hours.

Euphyllin (Theophylline) distributes poorly into body fat, therefore, mg/kg dose should be calculated on the basis of ideal body weight.

Table V contains Euphyllin (Theophylline) dosing titration schema recommended for patients in various age groups and clinical circumstances. Table VI contains recommendations for Euphyllin (Theophylline) dosage adjustment based upon serum Euphyllin (Theophylline) concentrations. Application of these general dosing recommendations to individual patients must take into account the unique clinical characteristics of each patient. In general, these recommendations should serve as the upper limit for dosage adjustments in order to decrease the risk of potentially serious adverse events associated with unexpected large increases in serum Euphyllin (Theophylline) concentration.

Table V. Dosing initiation and titration (as anhydrous Euphyllin (Theophylline)). *

  • A. Children (12-15 years) and adults (16-60 years) without risk factors for impaired clearance.
Titration Step Children <45 kg Children >45 kg and adults
1If caffeine-like adverse effects occur, then consideration should be given to a lower dose and titrating the dose more slowly (see ADVERSE REACTIONS ).
  • Starting Dosage
12-14 mg/kg/day up to a maximum of 300 mg/day admin. QD* 300-400 mg/day1 admin. QD*
  • After 3 days, if tolerated, increase dose to:
16 mg/kg/day up to a maximum of 400 mg/day admin. QD* 400-600 mg/day1 admin. QD*
  • After 3 more days, if tolerated, and if needed increase dose to:
20 mg/kg/day up to a maximum of 600 mg/day admin. QD* As with all Euphyllin (Theophylline) products, doses greater than 600 mg should be titrated according to blood level
  • B. Patients With Risk Factors For Impaired Clearance, The Elderly (>60 Years), And Those In Whom It Is Not Feasible To Monitor Serum Euphyllin (Theophylline) Concentrations:

    • In children 12-15 years of age, the Euphyllin (Theophylline) dose should not exceed 16 mg/kg/day up to a maximum of 400 mg/day in the presence of risk factors for reduced Euphyllin (Theophylline) clearance (see WARNINGS ) or if it is not feasible to monitor serum Euphyllin (Theophylline) concentrations.

    • In adolescents ≥16 years and adults, including the elderly, the Euphyllin (Theophylline) dose should not exceed 400 mg/day in the presence of risk factors for reduced Euphyllin (Theophylline) clearance (see WARNINGS ) or if it is not feasible to monitor serum Euphyllin (Theophylline) concentrations.

*Patients with more rapid metabolism clinically identified by higher than average dose requirements, should receive a smaller dose more frequently (every 12 hours) to prevent breakthrough symptoms resulting from low trough concentrations before the next dose.

Peak Serum

Concentration

Dosage Adjustment
¶Dose reduction and/or serum Euphyllin (Theophylline) concentration measurement is indicated whenever adverse effects are present physiologic abnormalities that can reduce Euphyllin (Theophylline) clearance occur (e.g. sustained fever), or a drug that interacts with Euphyllin (Theophylline) is added or discontinued (see WARNINGS ).
<9.9 mcg/mL If symptoms are not controlled and current dosage is tolerated, increase dose about 25%. Recheck serum concentration after three days for further dosage adjustment.
10-14.9 mcg/mL If symptoms are controlled and current dosage is tolerated, maintain dose and recheck serum concentration at 6-12 month intervals.¶ If symptoms are not controlled and current dosage is tolerated consider adding additional medication(s) to treatment regimen.
15-19.9 mcg/mL Consider 10% decrease in dose to provide greater margin of safety even if current dosage is tolerated. ¶
20-24.9 mcg/mL Decrease dose by 25% even if no adverse effects are present. Recheck serum concentration after 3 days to guide further dosage adjustment.
25-30 mcg/mL Skip next dose and decrease subsequent doses at least 25% even if no adverse effects are present. Recheck serum concentration after 3 days to guide further dosage adjustment. If symptomatic, consider whether overdose treatment is indicated.
>30 mcg/mL Treat overdose as indicated. If Euphyllin (Theophylline) is subsequently resumed, decrease dose by at least 50% and recheck serum concentration after 3 days to guide further dosage adjustment.

HOW SUPPLIED

Euphyllin (Theophylline)® (theophylline, anhydrous) Controlled-Release Tablets 400 mg are supplied in white, opaque plastic, child-resistant bottles containing 100 tablets (NDC 67781-251-01) or 500 tablets (NDC 67781-251-05). Each round, white 400 mg tablet bears the symbol PF on the scored side and U400 on the other side.

Euphyllin (Theophylline)® (theophylline, anhydrous) Controlled-Release Tablets 600 mg are supplied in white, opaque plastic, child-resistant bottles containing 100 tablets (NDC 67781-252-01). Each rectangular, concave, white 600 mg tablet bears the symbol PF on the scored side and U 600 on the other side.

Store at 25°C (77°F); excursions permitted between 15°-30°C (59°-86°F).

Dispense in a tight, light-resistant container.

©2011, Purdue Pharmaceutical Products L.P.

Dist. by: Purdue Pharmaceutical Products L.P.

Stamford, CT 06901-3431

Revised 10/2011

300945-0B

Euphyllin (Theophylline) Tablets

400 mg Tablets

NDC 677781-251-01

Euphyllin (Theophylline) Tablets 400 mg Tablets NDC 677781-251-01

Euphyllin (Theophylline) Tablets

600 mg Tablets

NDC 677781-252-01

Euphyllin (Theophylline) Tablets 600 mg Tablets NDC 677781-252-01

Euphyllin pharmaceutical active ingredients containing related brand and generic drugs:

Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.


Euphyllin available forms, composition, doses:

Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.


Euphyllin destination | category:

Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.


Euphyllin Anatomical Therapeutic Chemical codes:

A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.


Euphyllin pharmaceutical companies:

Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.


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References

  1. Dailymed."THEOPHYLLINE SOLUTION [SILARX PHARMACEUTICALS, INC]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  2. Dailymed."THEOPHYLLINE: DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts).". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  3. Dailymed."AMINOPHYLLINE: DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts).". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).

Frequently asked Questions

Can i drive or operate heavy machine after consuming Euphyllin?

Depending on the reaction of the Euphyllin after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Euphyllin not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.

Is Euphyllin addictive or habit forming?

Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.

Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.

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Review

sdrugs.com conducted a study on Euphyllin, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Euphyllin consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.

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According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 1-5mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
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1-5mg1
100.0%

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The information was verified by Dr. Arunabha Ray, MD Pharmacology

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