Pharmacological management—oral treatmentBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7556.1497 (Published 22 June 2006) Cite this as: BMJ 2006;332:1497
- Graeme P Currie, specialist registrar,
- Daniel K C Lee, specialist registrar,
- Brian J Lipworth, professor
- Respiratory Unit, Aberdeen Royal Infirmary, Aberdeen
- Department of Respiratory Medicine, Papworth Hospital, Papworth Everard, Cambridge
- Asthma and Allergy Research Group, Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, Dundee
Inhaled treatment forms the cornerstone of drug management of chronic obstructive pulmonary disease (COPD). However, some patients—especially those who are elderly, cognitively impaired, or with upper limb musculoskeletal problems—are unable to use inhaler devices successfully.
Theophylline is one of the oldest oral bronchodilators available for the treatment of COPD. It has a similar chemical structure to caffeine, which is also a bronchodilator in large amounts.
Theophylline is a non-selective phosphodiesterase inhibitor, and it causes an increase in the intracellular concentration of cyclic AMP in various cell types and organs (including the lung). Increased cyclic AMP concentrations are implicated in inhibition of inflammatory and immunomodulatory cells. One result is that phosphodiesterase inhibition causes smooth muscle relaxation and airway dilation.
Other potentially beneficial mechanisms of action of theophylline in COPD have been suggested, including
Reduction of diaphragmatic muscle fatigue
Increased mucociliary clearance
Respiratory centre stimulation
Inhibition of neutrophilic inflammation
Suppression of inflammatory genes by activation of histone deacetylases
Inhibition of cytokines and other inflammatory cell mediators
Potentiation of anti-inflammatory effects of inhaled corticosteroids
Potentiation of bronchodilator effects of β2 agonists.
Clinical use of theophylline
Consider a long acting theophylline preparation in patients with advanced COPD, especially when symptoms persist despite the use of inhaled long acting bronchodilators or in patients unable to use inhaler devices. Studies have shown that theophylline generally …