Theophylline

Peter J Barnes, Peter J Barnes

Abstract

Theophylline (3-methyxanthine) has been used to treat airway diseases for over 70 years. It was originally used as a bronchodilator but the relatively high doses required are associated with frequent side effects, so its use declined as inhaled β₂-agonists became more widely used. More recently it has been shown to have anti-inflammatory effects in asthma and COPD at lower concentrations. The molecular mechanism of bronchodilatation is inhibition of phosphodiesterase(PDE)3 and PDE4, but the anti-inflammatory effect may be due to histone deacetylase (HDAC) activation, resulting in switching off of activated inflammatory genes. Through this mechanism theophylline also reverses corticosteroid resistance and this may be of particular value in severe asthma and COPD where HDAC2 activity is markedly reduced. Theophylline is given systemically (orally as slow-release preparations for chronic treatment and intravenously for acute exacerbations of asthma) and blood concentrations are determined mainly by hepatic metabolism, which may be increased or decreased in several diseases and by concomitant drug therapy. Theophylline is now usually used as an add-on therapy in asthma patients not well controlled on inhaled corticosteroids and in COPD patients with severe disease not controlled by bronchodilator therapy. Side effects are related to plasma concentrations and include nausea, vomiting and headaches due to PDE inhibition and at higher concentrations to cardiac arrhythmias and seizures due to adenosine A₁-receptor antagonism.

Keywords: adenosine receptor; bronchodilatation; drug interaction; histone deacetylase; immunomodulation; inflammation; methylxanthine; phosphodiesterase; plasma concentration.

Figures

Figure 1
Figure 1
Effect of phosphodiesterase (PDE) inhibitors in the breakdown of cyclic nucleotides in airway smooth muscle and inflammatory cells.
Figure 2
Figure 2
Theophylline directly activates histone deacetylases (HDACs) which deacetylate core histones that have been acetylated by the histone acetyltransferase (HAT) activity of co-activators, such as CREB-binding protein (CBP). This results in suppression of inflammatory genes and proteins, such as granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin-8 (IL-8) that have been switched on by proinflammatory transcription factors, such as nuclear factor-κB (NF-κB). Corticosteroids also activate HDACs, but through a different mechanism resulting in the recruitment of HDACs to the activated transcriptional complex via activation of the glucocorticoid receptors (GR) which function as a molecular bridge. This predicts that theophylline and corticosteroids may have a synergistic effect in repressing inflammatory gene expression.
Figure 3
Figure 3
Multiple cellular effects of theophylline.

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