Is it safe to use Deriphyllin (theophylline) in a 68-year-old female with old coronary artery disease (CAD)?

Safety of Deriphyllin (Theophylline) in an Elderly Female with CAD

Deriphyllin (theophylline) should be avoided in a 68-year-old female with coronary artery disease due to significant cardiac risks, particularly the increased risk of arrhythmias and potential exacerbation of underlying heart disease. 1

Risks of Theophylline in Elderly CAD Patients

Cardiac Concerns

• The FDA drug label explicitly warns that theophylline should be used with "extreme caution" in patients with cardiac arrhythmias and requires dose reduction in elderly patients (>60 years) due to reduced clearance 1
• Theophylline can induce atrial fibrillation (AF), which is particularly concerning in patients with pre-existing CAD 2
• Elderly patients are significantly more susceptible to theophylline toxicity than younger patients due to:
  • Reduced drug clearance
  • Decreased protein binding (resulting in higher active drug levels)
  • Increased sensitivity to toxic effects 1

Age-Related Pharmacokinetic Changes

• Patients over 60 years have altered theophylline metabolism, leading to:
  • Higher serum concentrations at standard doses
  • Prolonged half-life
  • Increased risk of toxicity 1
• The FDA recommends that the maximum daily dose in patients >60 years should not exceed 400 mg/day unless the patient remains symptomatic and serum levels are <10 mcg/mL 1

Specific Cardiac Risks

Arrhythmias

• Theophylline can cause various cardiac arrhythmias including:
  • Sinus tachycardia (very common)
  • Supraventricular ectopic beats
  • Ventricular premature beats
  • In severe cases, ventricular tachycardia 3
• Research shows that elderly patients with heart disease are at higher risk for complex ventricular ectopy during theophylline therapy 3

CAD-Specific Concerns

• Coronary artery disease is specifically listed as a risk factor for theophylline-induced atrial fibrillation 2
• The drug can increase heart rate and myocardial oxygen demand, potentially worsening ischemia in patients with CAD

Alternative Approaches

For a 68-year-old female with CAD requiring bronchodilation:

• Consider safer alternatives such as inhaled beta-2 selective agonists and inhaled corticosteroids
• If bronchodilation is needed, inhaled medications generally have fewer systemic cardiac effects than theophylline
• The American Heart Association guidelines emphasize the importance of careful medication selection in elderly patients with CAD to avoid adverse cardiovascular outcomes 2

Monitoring Requirements If Used

If theophylline must be used despite these concerns:

• Start with a significantly reduced dose (no more than 400 mg/day) 1
• Monitor serum theophylline concentrations frequently
• Watch carefully for signs of toxicity (nausea, vomiting, tachycardia, arrhythmias)
• Consider ECG monitoring, especially during dose adjustments
• Discontinue immediately if any cardiac symptoms develop

Conclusion

Given the significant cardiac risks, particularly in an elderly female with existing CAD, safer alternatives to Deriphyllin (theophylline) should be strongly considered. The potential for arrhythmias, exacerbation of ischemia, and age-related toxicity makes this medication a high-risk choice in this specific patient population.