Theophylline: recent advances in the understanding of its mode of action and uses in clinical practice

Drug-Induced Insomnia and Excessive Sleepiness

Undesirable side effects of insomnia and/or sleepiness may occur with many prescribed drugs, psychotropics as well as non-psychotropics. These central nervous system effects can be explained by the interactions of the drug with any of the numerous neurotransmitters and receptors that are involved in sleep and wakefulness. Also a close - sometimes bidirectional - relationship between disease and (disturbed) sleep/wakefulness is often present e.g. in chronic pain; drug effects may lead this vicious circle in both ways. Besides the importance for health and quality of life, effects on sleep or waking function can be a potential source of non-compliance.

A Disposable Sensor Chip Using a Paste Electrode with Surface-Imprinted Graphite Particles for Rapid and Reagentless Monitoring of Theophylline

This work focuses on a carbon-based imprinted polymer composite, employed as a molecular recognition and sensing interface in fabricating a disposable electrochemical sensor. The carbon-paste electrode was made of a molecularly imprinted polymer comprising a copolymer of methacrylic acid as the functional monomer and blended crosslinking monomers of N,N′-methylenebisacrylamide, and ethylene glycol dimethacrylate, with theophylline as the template. The analytical properties of the proposed theophylline sensor were investigated, and the findings revealed an increase in differential pulse voltammetric current compared to the non-imprinted electrode. Under optimized conditions, the sensor has shown high sensitivity, high selectivity, lower detection limit (2.5 µg/mL), and satisfactory long-term stability. Further, the sensor was tested in whole bovine blood and validated without any matrix effect and cross-reactivity. Additionally, chronoamperometry of the sensor chip supported a rapid determination of THO with a short response time of 3 s. This carbon-paste electrode is highly specific for theophylline and may be applied as a drug sensor for clinical use.

Theophylline: Old Drug in a New Light, Application in COVID-19 through Computational Studies

Theophylline (3-methyxanthine) is a historically prominent drug used to treat respiratory diseases, alone or in combination with other drugs. The rapid onset of the COVID-19 pandemic urged the development of effective pharmacological treatments to directly attack the development of new variants of the SARS-CoV-2 virus and possess a therapeutical battery of compounds that could improve the current management of the disease worldwide. In this context, theophylline, through bronchodilatory, immunomodulatory, and potentially antiviral mechanisms, is an interesting proposal as an adjuvant in the treatment of COVID-19 patients. Nevertheless, it is essential to understand how this compound could behave against such a disease, not only at a pharmacodynamic but also at a pharmacokinetic level. In this sense, the quickest approach in drug discovery is through different computational methods, either from network pharmacology or from quantitative systems pharmacology approaches. In the present review, we explore the possibility of using theophylline in the treatment of COVID-19 patients since it seems to be a relevant candidate by aiming at several immunological targets involved in the pathophysiology of the disease. Theophylline down-regulates the inflammatory processes activated by SARS-CoV-2 through various mechanisms, and herein, they are discussed by reviewing computational simulation studies and their different applications and effects.

A "Single-Use" Ceramic-Based Electrochemical Sensor Chip Using Molecularly Imprinted Carbon Paste Electrode

An inexpensive disposable electrochemical drug sensor for the detection of drugs (vancomycin, meropenem, theophylline, and phenobarbital) is described. Molecularly imprinted polymer (MIP) templated with the target drugs was immobilized on the surface of graphite particles using a simple radical polymerization method and packed into the working electrode of a three-electrode ceramic-based chip sensor. Differential pulse voltammetry (DPV) was used to determine the relationship between the response current and the concentration of the targeted drug while using one sensor chip for one single operation. The time required for each DPV measurement was less than 2 min. Concentrations corresponding to the therapeutic range of these drugs in plasma were taken into account while performing DPV. In all the cases, the single-used MIP sensor showed higher sensitivity and linearity than non-imprinted polymer. The selectivity test in drugs with a structure similar to that of the target drugs was performed, and it was found that MIP-based sensors were more selective than the untreated ones. Additionally, the test in whole blood showed that the presence of interfering species had an insignificant effect on the diagnostic responses of the sensor. These results demonstrate that the disposable MIP-sensor is promising for quick and straightforward therapeutic drug monitoring to prevent the toxic side effects and the insufficient therapeutic effect due to the overdose and underdose, respectively.

Aminophylline suppresses stress-induced visceral hypersensitivity and defecation in irritable bowel syndrome

Pharmacological therapy for irritable bowel syndrome (IBS) has not been established. In order to find candidate drugs for IBS with diarrhea (IBS-D), we screened a compound library of drugs clinically used for their ability to prevent stress-induced defecation and visceral hypersensitivity in rats. We selected the bronchodilator aminophylline from this library. Using a specific inhibitor for each subtype of adenosine receptors (ARs) and phosphodiesterases (PDEs), we found that both A2BARs and PDE4 are probably mediated the inhibitory effect of aminophylline on wrap restraint stress (WRS)-induced defecation. Aminophylline suppressed maternal separation- and acetic acid administration-induced visceral hypersensitivity to colorectal distension (CRD), which was mediated by both A2AARs and A2BARs. We propose that aminophylline is a candidate drug for IBS-D because of its efficacy in both of stress-induced defecation and visceral hypersensitivity, as we observed here, and because it is clinically safe.

A fatal case of acute progression of generalized edema and simultaneous flash pulmonary edema in a patient with idiopathic systemic capillary leak syndrome: a case report

Introduction

Idiopathic systemic capillary leak syndrome is a rare and fatal disease due to the unexplained episodic attacks of capillary leakage of plasma from the intravascular into the interstitial space. The attack consists of three phases, a prodromal phase, peripheral leak phase and recruitment phase. During the peripheral leak phase, generalized edema, mainly in the trunk and extremities, with hemoconcentration and hypoalbuminemia occurs, while usually the visceral organs like lungs, brain, heart and kidneys seem not to be involved. Treatment of the acute phase is supportive, focusing on adequate but not overzealous fluid resuscitation, because pulmonary edema usually occurs in the recruitment phase.

Case presentation

A 65-year-old Japanese woman was admitted to our hospital because of severe hypovolemic shock with metabolic acidosis and hemoconcentration and hypoalbuminemia. Although she was considered to be in the peripheral leak phase of idiopathic systemic capillary leak syndrome, which could not be diagnosed during the treatment, the generalized edema worsened further, severe flash pulmonary edema progressed rapidly after fluid resuscitation and she died. The autopsy showed generalized edema, especially alveolar pulmonary edema without endothelial apoptosis.

Conclusions

Because hypovolemic shock and fatal pulmonary edema may progress rapidly together even in the peripheral leak phase of idiopathic systemic capillary leak syndrome, we should keep in mind this rare and fatal disease and recognize the pathophysiology to treat it effectively when the patient has hypovolemia with metabolic acidosis.

An unusual case of swelling--Clarkson's syndrome

Clarkson's syndrome, also called idiopathic systemic capillary leak syndrome is a rare condition characterised by vascular hyper permeability resulting in extreme intravascular volume depletion. The syndrome is unique and almost paradoxical in its presentation, with findings initially suggesting overwhelming heart failure, but in reality the extra vascular fluid represents overt capillary leak, with ultimate intravascular volume depletion, a low output state and hypovolemic shock. Previously described characteristics have classically included severe oedema and anasarca with rapid, profound shock, typically accompanied by haemoconcentration. The authors describe a patient, initially seeming benign in presentation, who rapidly progressed with confusing findings of fluid overload by examination and imaging, ultimately manifesting these findings by severe capillary leak rather than hydrostatic oedema, with ultimate hypovolaemic shock, multisystem organ failure and death. Our aim is that by describing clinical, haemodynamic and pathologic descriptors of the disease, the authors can aid in increasing physician awareness of this unusual syndrome.

Effects of theophylline on radioiodide uptake in MCF-7 breast cancer and NIS gene-transduced SNU-C5 colon cancer cells

BACKGROUND

We investigated whether theophylline has the potential to increase radioiodide uptake in nonthyroidal cancer cells.

MATERIALS AND METHODS

MCF-7 cells that express endogenous sodium/iodide symporter (NIS) and SNU-C5 cells adenovirally transduced with the human NIS gene (SNU-C5/NIS) were treated with 10(-7)-2x10(-4) mol/L theophylline for 24 hours before incubation with (125)I, and then, radioiodide uptake and retention were measured. NIS expression was assessed by immunohistochemistry and Western blot analysis, using an antihuman NIS monoclonal antibody.

RESULTS

Theophylline at 10(-6)-2x10(-4) mol/L significantly and dose dependently augmented radioiodide uptake in MCF-7 cells and at 10(-6)-10(-5) mol/L in SNU-C5/NIS cells, without affecting radioiodide efflux. Abrogation by KClO(4)(-) demonstrated that the effect of theophylline occurred through specific iodide transport. Immunohistochemistry revealed dose-dependent increases of NIS staining in MCF-7 and SNU-C5/NIS cells by 10(-6)-10(-4) and 10(-6)-10(-5) mol/L theophylline, respectively. Western blot analysis demonstrated similar findings, showing increased expression of NIS on the membrane of SNU-C5/NIS and MCF-7 cells by theophylline treatment.

CONCLUSIONS

Theophylline can augment radioiodide uptake in breast cancer cells and NIS gene-transduced cancer cells through the upregulation of NIS expression. Therefore, further investigations are warranted to explore the potential utility of this phenomenon for enhancing radioiodide-based imaging and therapies of NIS gene-transduced cancer cells.

Computational studies of the binding modes of A 2A adenosine receptor antagonists

A molecular docking study was performed on several structurally diverse A(2A) AR antagonists, including xanthines, and non-xanthine type antagonists to investigate their binding modes with A(2A) adenosine receptor (AR), one of the four subtypes of AR, which is currently of great interest as a target for therapeutic intervention, in particular for Parkinson's disease. The high-affinity binding site was found to be a hydrophobic pocket with the involvement of hydrogen bonding interactions as well as pi-pi stacking interactions with the ligands. The detailed binding modes for both xanthine and non-xanthine type A(2A) antagonists were compared and the essential features were extracted and converted to database searchable queries for virtual screening study of novel A(2A) AR antagonists. Findings from this study are helpful for elucidating the binding pattern of A(2A) AR antagonists and for the design of novel active ligands.

3D-Pharmacophore Models for Selective A2A and A2B Adenosine Receptor Antagonists

Three-dimensional pharmacophore models were generated for A2A and A2B adenosine receptors (ARs) based on highly selective A2A and A2B antagonists using the Catalyst program. The best pharmacophore model for selective A2A antagonists (Hypo-A2A) was obtained through a careful validation process. Four features contained in Hypo-A2A (one ring aromatic feature (R), one positively ionizable feature (P), one hydrogen bond acceptor lipid feature (L), and one hydrophobic feature (H)) seem to be essential for antagonists in terms of binding activity and A2A AR selectivity. The best pharmacophore model for selective A2B antagonists (Hypo-A2B) was elaborated by modifying the Catalyst common features (HipHop) hypotheses generated from the selective A2B antagonists training set. Hypo-A2B also consists of four features: one ring aromatic feature (R), one hydrophobic aliphatic feature (Z), and two hydrogen bond acceptor lipid features (L). All features play an important role in A2B AR binding affinity and are essential for A2B selectivity. Both A2A and A2B pharmacophore models have been validated toward a wide set of test molecules containing structurally diverse selective antagonists of all AR subtypes. They are capable of identifying correspondingly high potent antagonists and differentiating antagonists between subtypes. The results of our study will act as a valuable tool for retrieving structurally diverse compounds with desired biological activities and designing novel selective adenosine receptor ligands.

Oral xanthines as maintenance treatment for asthma in children

BACKGROUND

Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti-inflammatory effects. The current role of xanthines in the long-term treatment of childhood asthma needs to be reassessed.

OBJECTIVES

To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma.

SEARCH STRATEGY

A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2005.

SELECTION CRITERIA

Randomised controlled trials,lasting at least four weeks comparing a xanthine with placebo, regular short-acting beta-agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom-free days.

MAIN RESULTS

Thirty-four studies (2734 participants) of adequate quality were included. Xanthine versus placebo (17 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV1 , and PEF were better with xanthine. Xanthine was associated with non - specific side-effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta-agonist. Beta-agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro-intestinal side-effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated.

AUTHORS' CONCLUSIONS

Xanthines as first-line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add-on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first-line preventative asthma therapy in children when ICS are not available. They may have a role as add-on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk-benefit ratio compared with other agents.

Methylxanthines for prolonged non-specific cough in children

BACKGROUND

Non-specific cough is defined as non-productive cough in the absence of identifiable respiratory disease or known aetiology. It is commonly seen in paediatric practice. These children are treated with a variety of therapies including a variety of asthma medications. Methylxanthines, the main medication used for paediatric asthma for many decades in Western countries, is still widely used in non-Western countries. Also, methylxanthines have other pharmacological properties and their bronchodilator effect is only modest.

OBJECTIVES

To evaluate the efficacy of methylxanthines in treating children with non-specific cough.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in Jan 2005.

SELECTION CRITERIA

All randomised controlled trials comparing methylxanthines with a placebo medication in treating children with non-specific cough.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. No eligible trials were identified and thus no data were available for analysis. Four small non-randomised controlled trials were reported.

MAIN RESULTS

No randomised controlled trials that examined the efficacy of methylxanthines in the management of prolonged non-specific cough in children were found. In the non randomised trials above, a significant effect was seen within 2-14 days of therapy.

AUTHORS' CONCLUSIONS

There is currently an absence of reliable evidence to support the routine use of methylxanthines for symptomatic control of non-specific cough in children. If methylxanthines were to be trialled in children with prolonged non-specific cough, cohort data (thus limited) suggest a clinical response (subjective cough severity) would be seen within 2-5 days (and certainly within 14 days) of therapy. However methylxanthine use has to be balanced against the well known risk of toxicity and its low therapeutic range in children. Further research examining the efficacy of this intervention is needed.

Role of non-selective adenosine receptor blockade and phosphodiesterase inhibition in cisplatin-induced nephrogonadal toxicity in rats

1. It is well documented that cisplatin (CDDP) treatment increases the expression of adenosine A(1) receptors in both kidney and testes. However, the effect of adenosine at these receptors is controversial. Adenosine A(1) receptors have been documented to be involved in either cytoprotection or aggravation of nephrotoxicity. The aim of the present study was to examine the effect of the non-selective adenosine receptor inhibitor theophylline and the phosphodiesterase inhibitor pentoxifylline on CDDP-induced renal and testicular toxicity. 2. Male Wister rats were divided into six groups. Two control groups received plain drinking water and a third control group received theophylline 0.8 mg/mL in the drinking water for 2 weeks. One group of animals drinking plain water was injected intraperitoneally (i.p.) with pentoxifylline 50 mg/kg per day for 2 weeks. The remaining groups were treated in the same manner and received single dose of CDDP 7 mg/kg, i.p., 1 week after starting theophylline and pentoxifylline treatment and all animals were killed 1 week after CDDP treatment. 3. Rats treated with CDDP developed nephrotoxicity, as demonstrated by increased kidney and testes weight as a percentage of total bodyweight, blood urea nitrogen and serum creatinine levels and decreased serum calcium and albumin levels. In addition, CDDP treatment resulted in an increase in the production of malondialdehyde (MDA) and decreases in total nitrate/nitrite levels, as well as depletion of reduced glutathione (GSH) content and glutathione peroxidase (GPX) activity in both the kidney and testes. Administration of theophylline in the drinking water to CDDP-treated rats resulted in exacerbation of the indices of nephrotoxicity, depletion of GSH content and GPX activity levels, with increased MDA production and platinum accumulation in both the kidney and testes. However, pentoxifylline administration reduced CDDP-induced biochemical changes and reduced platinum accumulation in both organs. Histopathological examination of the kidney revealed that CDDP treatment produced multifocal tubular atrophy, atypical reparative changes of the tubular epithelium and marked tubular necrosis. Animals treated with the theophylline/CDDP combination showed extensive widespread damage with intratubular calcification. However, pentoxifylline treatment ameliorated the overt changes induced by CDDP treatment. 4. Theophylline exacerbates the deleterious effects of CDDP on rat kidney and testes. However, pentoxifylline alleviates CDDP-induced renal and testicular toxicity.

Pharmacological approaches to stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) causes disabling, slowly progressive breathlessness on exertion, chronic cough and sputum production. Its natural history is punctuated by increasingly frequent exacerbations which in turn accelerate disease progression and reduce a patient's quality of life. COPD has previously been ignored in the mistaken belief that nothing could be done. There are now a number of therapies that can be used to reduce symptoms and prevent exacerbations. In turn this reduces disability, improves the patient's health-related quality of life and has the potential to reduce costs to the health service and to society.

Prophylaxis of Iodinated Contrast Media-Induced Nephropathy

Iodinated contrast media are a frequent cause of acute renal failure, especially in patients whose renal function is already impaired. In addition to hydration, which remains the most commonly acknowledged means of protection, numerous pharmacological approaches for the prophylaxis of contrast nephropathy have been tested so far. They include diuretics, calcium channel blockers, adenosine receptor antagonists, N-acetylcysteine, low-dose dopamine and the dopamine D1 receptor agonist fenoldopam, endothelin receptor antagonists, and even captopril. The present review of the literature critically discusses the drugs used to prevent contrast nephropathy from a pharmacological point of view.

Inibidores de fosfodiesterases: novas perspectivas de uma antiga terapia na asma?

A asma é uma doença inflamatória crônica com níveis variados de obstrução ao fluxo aéreo e diferentes formas de apresentação. Seu tratamento vem sendo modificado com a evolução do conhecimento sobre sua patogenia. A inflamação das vias aéreas, que é modulada por determinantes genéticos e ambientais, resulta na alteração definitiva da arquitetura da via aérea (remodelamento). O padrão inflamatório da asma é de natureza multicelular, envolvendo mastócitos, neutrófilos, eosinófilos, linfócitos T, células musculares e epiteliais. Diversas citocinas e quimiocinas contribuem para a orquestração do processo inflamatório. O reconhecimento do papel crítico da inflamação, que está associada à gravidade da doença, vem direcionando o eixo do tratamento para a prevenção ou para o bloqueio das alterações inflamatórias. Nesse sentido, além dos agentes beta2-adrenérgicos, da teofilina e dos corticosteróides, novos fármacos vêm sendo estudados. Dentre eles, os inibidores específicos de fosfodiesterases vêm apresentando resultados promissores. A partir dos resultados obtidos com a segunda geração dessas substâncias, pode-se imaginar que, em breve, elas representarão uma nova opção para o tratamento da asma.

Advances in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible airflow limitation with extreme economic and social burden. It is estimated that over the next two decades, it will become the 5(th) most prevalent disease and the 3(rd) most common cause of death in the world. A better understanding of the pathogenesis of airway inflammation and alveolar destruction allows for the development of new therapeutic targets. Tobacco smoking is the most important risk factor in the development of COPD, thus making smoking cessation of the outermost importance. This article provides a critical review of present therapy for COPD. In addition to conventional treatment (bronchodilators, corticosteroids and antibiotics) and smoking cessation therapies, novel approaches with potential benefit are discussed.

Role of changes in tissular nucleotides on the development of apoptosis during ischemia/reperfusion in rat small bowel

The aim of this study was to evaluate whether xanthine and adenosine, substances modified proportionally to the duration of ischemia, can determine cell demise (apoptosis/necrosis) during intestinal ischemia/reperfusion (I/R) and to determine the role of nitric oxide (NO) during this process. The following experimental groups were studied: I, cold ischemia; I+X, effect of xanthine; I+T, effect of adenosine (blocking its receptor by theophylline); I+A, effect of excess adenosine; I+T+X, effect of xanthine alone, and I+T+ spermine NONOate (NONOs), I+A+NONOs, I+X+NONOs, role of NO. DNA fragmentation, xanthine/adenosine levels, caspase-3 activity, NO generation, and histological analysis were measured in tissue samples. The rats treated with xanthine or adenosine showed increased levels of caspase-3 activity and DNA fragmentation. In contrast, theophylline-treated rats showed decreased levels of DNA fragmentation and tended to show lower mean values of caspase-3 activity. Administration of xanthine or NONOs to theophylline-treated rats reversed these effects. The results of histological evaluation were in agreement with these previous results. In conclusion, the present study indicates that xanthine and adenosine induced an apoptotic response during cold ischemic preservation of rat small intestine. In particular, the action of adenosine on apoptotic events was mediated by NO. We consider that identification of the role of these factors may help to define the best conditions of tissue preservation before intestinal transplantation.

Glucose-induced islet blood flow increase in rats: interaction between nervous and metabolic mediators

This study investigated the mechanisms for glucose-induced islet blood flow increase in rats. The effects of adenosine, adenosine receptor antagonists, and vagotomy on islet blood flow were evaluated with a microsphere technique. Vagotomy prevented the islet blood flow increase expected 3, 10, and 20 min after injection of glucose, whereas theophylline (a nonspecific adenosine receptor antagonist) prevented the islet blood flow increase from occurring 10 and 20 min after glucose administration. Administration of selective adenosine receptor antagonists suggested that the response to theophylline was mediated by A1 receptors. Exogenous administration of adenosine did not affect islet blood flow, but local accumulation of adenosine, induced by the adenosine uptake inhibitor dipyridamole, caused a doubling of islet blood flow. In conclusion, the increased islet blood flow seen 3 min after induction of hyperglycemia is caused by the vagal nerve, whereas the increase in islet blood perfusion seen at 10 and 20 min after glucose administration is caused by both the vagal nerve and adenosine.

Using case management to increase antiinflammatory medication use among a managed care population with asthma

The National Heart, Lung, and Blood Institute (NHLBI) recommends the regular use of antiinflammatory medications to achieve and maintain control of persistent asthma, while recommending that quick-relief beta2-agonist medications should be used to treat acute symptoms and exacerbations. Despite these suggestions, the overuse of short-acting quick-relief medications and underuse of long-acting antiinflammatory medications persists. ConnectiCare, Inc., a regional managed care company, used pharmacy claims data to identify members who had been dispensed a total of three or more beta2-agonist prescriptions for three consecutive months in a 12-month period. These members had also not been prescribed an inhaled corticosteroid, cromolyn sodium, or nedocromil during the same three consecutive months. An intensive case management intervention was developed that included multiple contacts from a nurse case manager to provide education and information about asthma control and the guidelines. Twenty-eight percent (n = 40) were purposively chosen to receive the intensive multiple-contact intervention and the remainder received a standard, single-contact intervention. After adjusting for the effects of age, gender, and pre-intervention medication use, ConnectiCare members who received the intensive intervention were 4.3 times more likely to increase the number of antiinflammatory medication prescriptions dispensed that those who received a standard intervention (p < 0.001). This study suggests that the use of intensive case management for persons identified as inappropriate users of asthma medication may result in medication changes that achieve the long-term control of asthma.

New clinical applications of xanthine derivatives: modulatory actions on leukocyte survival and function

The use of theophylline in the treatment of obstructive pulmonary diseases has diminished with the advent of new medications. However, its use as a second-line bronchodilator has been reconsidered in recent years. Theophylline is reported to have immunomodulatory actions that may account for its clinical effectiveness in the control of airway inflammation. Theophylline, even at low plasma concentrations, inhibits the late asthmatic reaction following allergen challenge. The apparent suppression of airway inflammation by theophylline reinforces findings from in vitro experiments (including our recent studies). Its immunomodulatory actions include inhibition of cytokine synthesis and release, inhibition of inflammatory cell activation, and acceleration of granulocyte apoptosis. On the basis of these findings, theophylline has been re-evaluated as a key drug for the long-term management of bronchial asthma, and new applications are proposed for the clinical use of xanthine derivatives. Here, we review some recent advances in the understanding of pharmacological actions and new applications of xanthine derivatives.

Novel selective PDE4 inhibitors. 1. Synthesis, structure-activity relationships, and molecular modeling of 4-(3,4-dimethoxyphenyl)-2H-phthalazin-1-ones and analogues

A number of 6-(3,4-dimethoxyphenyl)-4,5-dihydro-2H-pyridazin-3-ones and a novel series of 4-(3,4-dimethoxyphenyl)-2H-phthalazin-1-ones were prepared and tested on the cGMP-inhibited phosphodiesterase (PDE3) and cAMP-specific phosphodiesterase (PDE4) enzymes. All tested compounds were found to specifically inhibit PDE4 except for pyridazinone 3b, which showed moderate PDE4 (pIC(50) = 6.5) as well as PDE3 (pIC(50) = 6.6) inhibitory activity. In both the pyridazinone and phthlazinone series it was found that N-substitution is beneficial for PDE4 inhibition, whereas in the pyridazinone series it also accounts for PDE4 selectivity. In the phthalazinone series, the cis-4a,5,6,7,8,8a-hexahydrophthalazinones and their corresponding 4a,5,8,8a-tetrahydro analogues showed potent PDE4 inhibitory potency (10/11c,d: pIC(50) = 7.6-8.4). A molecular modeling study revealed that the cis-fused cyclohexa(e)ne rings occupy a region in space different from that occupied by the other fused (un)saturated hydrocarbon rings applied; we therefore assume that the steric interactions of these rings with the binding site play an important role in enzyme inhibition.

Efficacy of IV theophylline in children with severe status asthmaticus

STUDY OBJECTIVE

To determine whether adding IV theophylline to an aggressive regimen of inhaled and IV beta-agonists, inhaled ipratropium, and IV methylprednisolone would enhance the recovery of children with severe status asthmaticus admitted to the pediatric ICU (PICU).

DESIGN

A prospective, randomized, controlled trial. Asthma scoring was performed by investigators not involved in treatment decisions and blinded to group assignment.

SETTING

The PICU of an urban, university-affiliated, tertiary-care children's hospital.

PATIENTS

Children with a diagnosis of status asthmaticus who were admitted to the PICU for < or = 2 h and who were in severe distress, as indicated by a modified Wood-Downes clinical asthma score (CAS) of > or = 5.

INTERVENTIONS

All subjects initially received continuous albuterol nebulizations; intermittent, inhaled ipratropium; and IV methylprednisolone. The theophylline group was also administered infusions of IV theophylline to achieve serum concentrations of 12 to 17 microg/mL. A CAS was tabulated twice daily.

MEASUREMENTS AND RESULTS

Forty-seven children (median age, 8.3 years; range, 13 months to 17 years) completed the study. Twenty-three children received theophylline. The baseline CASs of both groups were similar and included three subjects receiving mechanical ventilation in each group. All subjects receiving mechanical ventilation and theophylline were intubated before drug infusion. Among the 41 subjects who were not receiving mechanical ventilation, those receiving theophylline achieved a CAS of < or = 3 sooner than control subjects (18.6 +/- 2.7 h vs 31.1 +/- 4.5 h; p < 0.05). Theophylline had no effect on the length of PICU stay or the total incidence of side effects. Subjects receiving theophylline had more emesis (p < 0.05), and control patients had more tremor (p < 0.05).

CONCLUSIONS

Theophylline safely hastened the recovery of children in severe status asthmaticus who were also receiving albuterol, ipratropium, and methylprednisolone. The role of theophylline in the management of asthmatic children in impending respiratory failure should be reexamined.

Theophylline metabolism after cardiac surgery

The effect and metabolism of theophylline administration after cardiac surgery has never been reported. Two series of 2-hour intravenous aminophylline administrations (3 mg/kg/h) were conducted in 10 adult patients on the operative day (acute phase) and on the 4th or 5th postoperative day (recovery phase). Both blood and urine samples were collected for 24 hours after dosing. Heart rate increased in both phases, but the cardiac index increased with the decrease of diastolic blood pressure only in the acute phase (p < 0.05). Plasma concentration levels of theophylline tended to be slightly higher in the acute phase, and renal clearance increased in the recovery phase (p < 0.05). The urinary ratio of 3-methylxanthine to theophylline was significantly higher in the acute phase (p < 0.05). This suggests that cytochrome P4501A2 is partially activated rather than depressed and that N-demethylation is promoted more than hydroxylation immediately after surgery.

The chronic obstructive pulmonary disease exacerbation

Chronic obstructive pulmonary disease is the only leading cause of death with a rising prevalence. The medical and economic costs arising from acute exacerbations of COPD are therefore expected to increase over the coming years. Although exacerbations may be initiated by multiple factors, the most common identifiable associations are with bacterial and viral infections. These are associated with approximately 50% to 70% and 20% to 30% of COPD exacerbations, respectively. In addition to smoking cessation, annual influenza vaccination is the most important method for preventing exacerbations. Controlled O2 is the most important intervention for patients with acute hypoxic respiratory failure. Evidence from randomized, controlled trials justifies the use of corticosteroids, bronchodilators (but not theophylline), noninvasive positive-pressure ventilation (in selected patients), and antibiotics, particularly for severe exacerbations. Antibiotics should be chosen according to the patient's risk for treatment failure and the potential for antibiotic resistance. In the acute setting, combined treatment with beta-agonist and anticholinergic bronchodilators is reasonable but not supported by randomized controlled studies. Physicians should identify and, when possible, correct malnutrition. Chest physiotherapy has no proven role in the management of acute exacerbations.

Chronic systemic capillary leak syndrome. Report of a case and review of the literature

Systemic capillary leak syndrome (SCLS) is a rare condition characterized by recurrent episodes of generalized oedema and severe hypotension, associated with paraproteinaemia. In addition to the acute form, a few cases of chronic SCLS have been reported. We describe a 64-year-old woman who was hospitalized because of a 6-month history of progressive generalized oedema with pericardial and pleural effusions, associated with a serum paraprotein. Clinical and laboratory findings were consistent with a chronic form of SCLS. Treatment with prednisone, furosemide and theophylline was started, which led to a gradual improvement in 2 weeks and a persistent remission after 9 months. This report indicates that SCLS may occur in a chronic form, which seems to be responsive to a therapeutic regimen with prednisone, furosemide, and theophylline.

Capillary electrophoretic analysis of alkaline phosphatase inhibition by theophylline

An analytical method for studying enzyme inhibition has been developed using capillary electrophoresis with laser-induced fluorescence detection. This technique is based on electrophoretic mixing of zones of enzyme and inhibitor in substrate-filled capillaries. Enzyme catalytic activity is measured by detecting the fluorescent reaction product as it migrates past the detector. Reversible enzyme inhibition is indicated by a transient decrease in product formation. The enzyme, alkaline phosphatase, has been studied using the fluorogenic substrate AttoPhos ([2,2'-bibenzothiazol]-6-hydroxy-benzthiazole phosphate). This assay has been used to quantify theophylline, a noncompetitive, reversible inhibitor of alkaline phosphatase. The detection limit for theophylline is estimated at 3 microM, and 8.6 amole of alkaline phosphatase are required for each assay. The calculated K(i) for theophylline is 90 microM for the capillary electrophoretic enzyme-inhibitor assays.

Anilide derivatives of an 8-phenylxanthine carboxylic congener are highly potent and selective antagonists at human A(2B) adenosine receptors

No highly selective antagonists of the A(2B) adenosine receptor (AR) have been reported; however such antagonists have therapeutic potential as antiasthmatic agents. Here we report the synthesis of potent and selective A(2B) receptor antagonists. The structure-activity relationships (SAR) of 8-phenyl-1, 3-di-(n-propyl)xanthine derivatives in binding to recombinant human A(2B) ARs in HEK-293 cells (HEK-A(2B)) and at other AR subtypes were explored. Various amide derivatives of 8-[4-[[carboxymethyl]oxy]phenyl]-1,3-di-(n-propyl)xanthine, 4a, were synthesized. A comparison of aryl, alkyl, and aralkyl amides demonstrated that simple anilides, particularly those substituted in the para-position with electron-withdrawing groups, such as nitro, cyano, and acetyl, bind selectively to human A(2B) receptors in the range of 1-3 nM. The unsubstituted anilide 12 had a K(i) value at A(2B) receptors of 1.48 nM but was only moderately selective versus human A(1)/A(2A) receptors and nonselective versus rat A(1) receptors. Highly potent and selective A(2B) antagonists were a p-aminoacetophenone derivative 20 (K(i) value 1.39 nM) and ap-cyanoanilide 27 (K(i) value 1.97 nM). Compound 27 was 400-, 245-, and 123-fold selective for human A(2B) receptors versus human A(1)/A(2A)/A(3) receptors, respectively, and 8.5- and 310-fold selective versus rat A(1)/A(2A) receptors, respectively. Substitution of the 1,3-dipropyl groups with 1,3-diethyl offered no disadvantage for selectivity, and high affinities at A(2B) receptors were maintained. Substitution of the p-carboxymethyloxy group of 4a and its amides with acrylic acid decreased affinity at A(2B) receptors while increasing affinity at A(1) receptors. 1, 3-Di(cyclohexylmethyl) groups greatly reduced affinity at ARs, although the p-carboxymethyloxy derivative 9 was moderately selective for A(2B) receptors. Several selective A(2B) antagonists inhibited NECA-stimulated calcium mobilization in HEK-A(2B) cells.

Age-related changes in airway responsiveness to phosphodiesterase inhibitors and activators of adenyl cyclase and guanylyl cyclase

The influence of animal age on the responsiveness of guinea-pig and rat isolated tracheal smooth muscle to the non-selective inhibitors of phosphodiesterase, theophylline and papaverine and to the adenylyl cyclase and soluble guanylyl cyclase activators, forskolin and sodium nitroprusside respectively, was examined. Significant age-related decreases in the potencies of theophylline and papaverine were observed across the age ranges in guinea-pig (2.8- and 3.4-fold decreases respectively) and rat (1.9- and 2.6-fold decreases respectively) trachea, suggesting age-related falls in the activity of phosphodiesterase in these tissues. However, maximum relaxant responses (E(max)) to these agents were not altered with increasing animal age. The relaxant potency of sodium nitroprusside also decreased 4.4-fold across the age range in guinea-pig isolated trachea but not in rat isolated tracheal tissue, suggesting age-related falls in soluble guanylyl cyclase activity in guinea-pig trachea. In contrast, neither forskolin potency nor E(max)changed significantly with increasing age in either guinea-pig or rat tracheal tissue. The present data indicate that ageing in both guinea-pigs and rats was associated with decreased relaxant potency of phosphodiesterase (PDE) inhibitors rather than to changes in adenylyl cyclase activity although reduced soluble guanylyl cyclase activity was also detected in the guinea-pig.

Lack of drug interaction between omeprazole, lansoprazole, pantoprazole and theophylline

AIMS

Theophylline is a model substrate of cytochrome P4501A2. The ability of the proton pump inhibitors (PPI) omeprazole, lansoprazole and pantoprazole to induce cytochrome P4501A2 has not yet been unequivocally resolved. The aim of this comprehensive study was to compare directly the effect of the three PPI on the absorption and disposition of theophylline.

METHODS

Twenty healthy, nonsmoking, male and female volunteers (extensive metabolisers of cytochrome P4502C19 and Helicobacter pylori negative) participated in a randomized, double-blind, four-period, placebo-controlled crossover study. In each of the four periods they received either omeprazole (40 mg), lansoprazole (60 mg), pantoprazole (80 mg) or placebo once daily for 10 days. Sustained release theophylline (350 mg twice daily) was coadministered from day 8-10. Pharmacokinetics of theophylline as well as of all three PPI were determined at steady-state (day 10).

RESULTS

In all periods, point estimates and 90% confidence intervals of the area under the concentration-time curves (AUC), maximum steady-state concentrations and peak-trough fluctuations of theophylline were not altered by PPI pretreatment and met the required limits for bioequivalence. Point estimates (90% confidence intervals) of the AUC ratios of theophylline plus PPI to theophylline alone were 0.92 (0.87-0.97), 0.90 (0.85-0.95) and 1.00 (0.95-1.06) for omeprazole, lansoprazole and pantoprazole, respectively.

CONCLUSIONS

Concomitant intake of omeprazole, lansoprazole or pantoprazole at high therapeutic doses does not affect the absorption and disposition of theophylline.

Hemodynamic and electrophysiologic effects of acute chocolate ingestion in young adults

The purpose of this study was to determine the hemodynamic and electrophysiologic effects of acute chocolate, and hence theobromine, ingestion on the hearts of young adults. Theobromine was not found to have any cardiovascular effects on subjects in this study.

Cyclic nucleotide phosphodiesterase (PDE) inhibitors and immunomodulation

Intracellular levels of cyclic nucleotide second messengers are regulated predominantly by the complex superfamily of cyclic nucleotide phosphodiesterase (PDE) enzymes. Recent advances in our understanding of the molecular pharmacology of these enzymes has led to their identification as biologic regulators of certain disease states and the development of isozyme-selective inhibitors as potential therapeutic agents. A large body of in vitro and preclinical data suggests the therapeutic utility of PDE4 inhibitors as potent anti-inflammatory agents. Early clinical trials with selective PDE inhibitors substantiate this approach while highlighting pharmacodynamic and toxicologic pitfalls inherent to the inhibition of specific PDE isozymes. This commentary will review our current understanding of PDE inhibitors as immunomodulatory agents.

Cyclic AMP induces inhibition of cyclin A expression and growth arrest in human hepatoma cells

Classical cytotoxic therapy has been minimally useful in the treatment of hepatocellular carcinoma. In an effort to develop a new approach to the treatment of this neoplasm, we have investigated the signal transduction pathways regulating the growth of human hepatoma cells. In the data reported here, cyclic AMP (cAMP), a negative growth regulator for many cells of epithelial origin, induced G1 synchronization and apoptosis in the HepG2 human hepatoma cell line. The effects of cAMP on the components of the G1/S transition were analyzed. There was no detectable effect of two different cAMP analogs, 8-bromo cAMP or dibutyryl cAMP on the level of the D-type cyclins, cyclin E, cyclin-dependent kinase 2, cyclin-dependent kinase 4, p53, or the cyclin-dependent kinase inhibitors p21 or p27. In contrast, the cAMP analogs induced a dramatic downregulation of cyclin A protein, cyclin A messenger RNA, and cyclin A-dependent kinase activity. Cyclin A-dependent kinase has been shown to be required for the G1-S transition. Furthermore, cyclin A deregulation has been implicated in the pathogenesis of hepatocellular carcinoma. The data reported here suggest a novel signal transduction-based approach to hepatoma therapy.

Theophylline. A review of its potential steroid sparing effects in asthma

Theophylline is generally considered to be a bronchodilatory drug. However, recent pharmacodynamic studies indicate that it has anti-inflammatory effects. It reduced eosinophil survival rates in vitro, and reduced eosinophil accumulation in bronchial tissue in patients with atopic asthma. Theophylline has also been shown to reduce T cell proliferation and accumulation. These changes were mirrored by improved pulmonary function in patients with asthma in studies that evaluated this parameter. Three randomised double-blind studies have evaluated the potential role of theophylline as an anti-inflammatory treatment in patients with asthma not controlled by low doses of inhaled corticosteroids. Patients were randomised to receive low dose theophylline (400 to 750 mg daily) plus low dose inhaled corticosteroids, or an increased dose of inhaled corticosteroids. Clinical pulmonary function improved to the same or a greater extent in patients who received low dose inhaled corticosteroids plus theophylline than in those treated with high dose inhaled corticosteroids plus placebo. Where reported, the dosages of theophylline used in these studies resulted in serum theophylline concentrations of approximately 9 to 10 mg/L. Approximate monthly costs were provided in one study: these were $60 (year and currency not specified) for theophylline plus budesonide 800 micrograms/day, compared with $100 for budesonide 1600 micrograms/day, and $155 for a regimen of budesonide 800 micrograms/day and salmeterol 100 micrograms/day.

CONCLUSIONS

Low dose theophylline has been shown to reduce requirements for inhaled corticosteroid therapy in patients with asthma and may reduce overall treatment costs.