The Use of IV Aminophylline in addition to beta-agonists and steroids in Acute Asthma
Date First Published:
September 25, 2005
Last Updated:
April 10, 2007
Report by:
Steven Cowman, SHO Accident and Emergency (Whipps Cross University Hospital)
Search checked by:
John Butler, Whipps Cross University Hospital
Three-Part Question:
In [adults presenting with an acute exacerbation of asthma] does [adding IV aminophylline to standard therapy] result in [improvement in airflow or other physiological parameters] OR [a reduction in mortality or morbidity or hospitalisation]?
Clinical Scenario:
A 30 year old known asthmatic presents with an acute severe attack of asthma. Despite administering continuous nebulised beta-agonists and intravenous corticosteroids, he fails to improve. You wonder whether adding an intravenous bolus of aminophylline followed by an infusion to his therapy would be beneficial.
Search Strategy:
The Cochrane Library 2007 Issue 1, searched on 26/03/2007.
MEDLINE 1999 to March Week 3 2007 using the OVID interface.
MEDLINE 1999 to March Week 3 2007 using the OVID interface.
Search Details:
COCHRANE: asthma AND aminophylline.
MEDLINE: [exp asthma/ OR asthma$.mp OR exp status asthmaticus/ OR status asthmaticus$.mp] AND [exp aminophylline/ OR aminophylline$.mp OR exp. xanthines/ OR methyl xanthine$.mp OR exp. theophylline or theophylline$.mp] AND [highly sensitive filter for randomised controlled trials] LIMIT to Human and English
MEDLINE: [exp asthma/ OR asthma$.mp OR exp status asthmaticus/ OR status asthmaticus$.mp] AND [exp aminophylline/ OR aminophylline$.mp OR exp. xanthines/ OR methyl xanthine$.mp OR exp. theophylline or theophylline$.mp] AND [highly sensitive filter for randomised controlled trials] LIMIT to Human and English
Outcome:
One systematic review was identified by the Cochrane Library search. The MEDLINE search identified 292 papers of which 290 were irrelevant or of insufficient quality, leaving 2 selected papers. The two identified papers were the Cochrane review and the other was a short commentary on the Cochrane review with no new additional evidence.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Addition of intravenous aminophylline to beta2-agonists in adults with acute asthma Parameswaran K, Belda J and Rowe BH 2000 | 739 adult patients (>18 years of age) from 17 randomised controlled trials, presenting with acute asthma in an acute care setting. 386 recieved standard care (oxygen and beta-agonists (nebulised or inhaled) +/- corticosteroids) 353 recieved standard care + IV aminophylline |
Systematic Review (Level 1a) | Change in PEFR at 05, 1, 12 and 24 hours after administration | No significant difference at any time. | Variety of outcome measures used between studies - both PEFR and FEV1, expressed both as % of predicted and absolute values. Baseline difference in PEFR and FEV1 between groups (lower values in pooled treatment group). Variety of beta-agonists used betwen trials and administered through a variety of routes; no subgroup analysis looking at the effect of this. Only three studies had samples sizes greater than 30 subjects. |
| Change in FEV1 at 0.5, 1, 12 and 24 hours after administration | No significant difference at any time. | ||||
| Hospitalization | No significant difference. | ||||
| Adverse Effects | Significantly higher incidence of palpitations and/or arrhythmias (OR 3.02 95%CI 1.2-7.9) and vomiting (OR 4.21 95%CI 2.2-8.1) in aminophylline group. No significant difference in incidence of tremor. Insufficient data to produce results for convulsion or hypokalaemia. |
Author Commentary:
The use of intravenous aminophylline as a routine agent in the treatment of acute asthmatics has declined in the last few years. In a recent observational paper by Kelly A-M et al (Internal Medicine Journal 2003;33:406-13.) looking at 1340 attendances to the ED with acute asthma only 6% of cases were treated with aminophylline. The Cochrane review failed to show any evidence of benefit especially in severe asthma.
The use of intravenous aminophylline was associated with a higher incidence of adverse effects compared to standard care alone. Whether or not aminophylline has a place as an additional therapy following treatment with proven medications such as inhaled B-agonists, systemic corticosteroids and intravenous magnesium remains uncertain.
The use of intravenous aminophylline was associated with a higher incidence of adverse effects compared to standard care alone. Whether or not aminophylline has a place as an additional therapy following treatment with proven medications such as inhaled B-agonists, systemic corticosteroids and intravenous magnesium remains uncertain.
Bottom Line:
Current evidence does not support the addition of intravenous aminophylline to standard care in adults with acute asthma.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Parameswaran K, Belda J and Rowe BH. Addition of intravenous aminophylline to beta2-agonists in adults with acute asthma