BNF for Children 2011-2012

142 3.1.3 Theophylline BNFC 2011–20123 Respiratory systemjunctival hyperaemia, corneal oedema, stomatitis,rash, pruritus; rarely atrial fibrillationIndication and doseAcute asthma. By inhalation of nebulised solutionSee Management of Acute Asthma, section 3.1Reversible airways obstruction see notes above. By aerosol inhalationChild 1 month–6 years 20 micrograms 3 timesdailyChild 6–12 years 20–40 micrograms 3 times dailyChild 12–18 years 20–40 micrograms 3–4 timesdaily. By inhalation of powderChild 12–18 years 40 micrograms 3–4 times daily(dose may be doubled in less responsive condition)Counselling Advise child and carer not to exceed prescribeddose and to follow manufacturer’s directionsRhinitis section 12.2.2Ipratropium Bromide (Non-proprietary) ANebuliser solution, ipratropium bromide 250 micrograms/mL,net price 20 1-mL (250-microgram)unit-dose vials = £6.75, 60 1-mL = £21.78; 20 2-mL (500-microgram) = £7.43, 60 2-mL = £26.97Atrovent c (Boehringer Ingelheim) AAerosol inhalationT, ipratropium bromide 20 micrograms/meteredinhalation, net price 200-dose unit =£5.05. Counselling, administrationNebuliser solution, isotonic, ipratropium bromide250 micrograms/mL, net price 20 1-mL unit-dosevials = £4.14, 60 1-mL vials = £12.44; 20 2-mLvials = £4.87, 60 2-mL vials = £14.59Ipratropium Steri-Neb c (IVAX) ANebuliser solution, isotonic, ipratropium bromide250 micrograms/mL, net price 20 1-mL (250-microgram) unit-dose vials = £8.72; 20 2-mL (500-microgram) = £9.94Respontin c (A&H) ANebuliser solution, isotonic, ipratropium bromide250 micrograms/mL, net price 20 1-mL (250-microgram) unit-dose vials = £4.78; 20 2-mL (500-microgram) = £5.603.1.3 TheophyllineTheophylline is a xanthine used as a bronchodilator inasthma, see Management of Chronic Asthma p. 135. Itmay have an additive effect when used in conjunctionwith small doses of beta 2 agonists; the combination mayincrease the risk of side-effects, including hypokalaemia(see p. 138).Theophylline is given by injection as aminophylline, amixture of theophylline with ethylenediamine, which is20 times more soluble than theophylline alone. Aminophyllineinjection is needed rarely for severe acuteasthma (see Management of Acute Asthma p. 136). Itmust be given by very slow intravenous injection (overat least 20 minutes) or by intravenous infusion; it is tooirritant for intramuscular use. Intravenous aminophyllinemay be used as a respiratory stimulant in neonateswith apnoea, but caffeine, a xanthine derivative, (section3.5.1) is usually preferred. Measurement of plasmatheophyllineconcentration may be helpful and is essentialif a loading dose of aminophylline is to be given tochildren who are already taking theophylline, becauseserious side-effects such as convulsions and arrhythmiascan occasionally precede other symptoms of toxicity.Theophylline is metabolised in the liver. The plasmatheophyllineconcentration is increased in heart failure,hepatic impairment, viral infections, and by drugs thatinhibit its metabolism. The plasma-theophylline concentrationis decreased in smokers, by alcohol consumption,and by drugs that induce its metabolism. Forinteractions of theophylline, see Appendix 1.Plasma-theophylline concentration In most individualsa plasma-theophylline concentration of 10–20 mg/litre (55–110 micromol/litre) is required forsatisfactory bronchodilation, but a lower concentrationof 5–15 mg/litre may be effective. Adverse effects canoccur within the range 10–20 mg/litre and both thefrequency and severity increase if the concentrationexceeds 20 mg/litre. In neonates, toxic symptomssometimes occur when the plasma-theophylline concentrationexceeds 14 mg/litre (78 micromol/litre). Iftheophylline is used in the treatment of neonatalapnoea, the usual target range is 8–12 mg/litre (44–66 micromol/litre).Plasma-theophylline concentration is measured 5 daysafter starting oral treatment and at least 3 days after anydose adjustment. A blood sample should be taken 1–2hours after an oral dose (after 4–6 hours in the case of amodified-release preparation). If aminophylline is givenintravenously, a blood sample should be taken 4–6 hoursafter starting treatment.THEOPHYLLINECautions see notes above; also cardiac arrhythmias orother cardiac disease, hypertension, hyperthyroidism;peptic ulcer; epilepsy; fever; hypokalaemia risk,p. 138; avoid in acute porphyria (section 9.8.2);monitor plasma-theophylline concentration (seenotes above); dose adjustment may be necessary ifsmoking started or stopped during treatment; interactions:Appendix 1 (theophylline) and notes aboveHepatic impairment reduce dosePregnancy neonatal irritability and apnoea reported;see also p. 133Breast-feeding present in milk—irritability in infantreported; modified-release preparations preferable;see also p. 133Side-effects nausea, vomiting, gastric irritation,diarrhoea, palpitation, tachycardia, arrhythmias,headache, CNS stimulation, insomnia, convulsionsoverdosage: see Emergency Treatment of Poisoning,p. 31Licensed use Slo-Phyllin c capsules not licensed foruse in children under 2 years