Inpatient theophylline toxicity: preventable factors

Area of Science:

• Pharmacology
• Clinical Pharmacy
• Patient Safety

Background:

• Theophylline is a medication used for respiratory conditions.
• Inpatient theophylline toxicity poses a significant risk to patient health.
• Identifying contributing factors is crucial for improving patient outcomes.

Observation:

• A case series reviewed 40 adult inpatients with theophylline levels exceeding 140 mumol/L.
• Toxicity occurred in 27 of these patients due to administration errors.
• Common errors included delayed response to toxic levels, inappropriate dosing in heart failure patients, and failure to recognize symptoms.

Findings:

• Management errors were identified as the primary cause of theophylline toxicity.
• Specific errors included dosing mistakes, delayed interventions, and inadequate monitoring.
• These errors contributed to recurrent toxicity and prolonged treatment.

Implications:

• Effective preventive measures can mitigate most inpatient theophylline toxicity.
• Addressing management errors can improve the risk-benefit ratio of theophylline therapy.
• Enhanced protocols for theophylline administration and monitoring are recommended.