Management of COPD with Theophylline

Recommendation Against Theophylline Use

The Canadian Thoracic Society recommends against the use of theophylline as add-on therapy in patients with stable COPD who are already receiving monotherapy with LAMA, monotherapy with LABA, or dual LAMA/LABA therapy, due to the low certainty of clinical benefits and the high risk of adverse effects and drug interactions 1
The American College of Chest Physicians suggests that theophylline should not be added to patients with stable COPD who are already on treatment with LAMA, LABA, or dual LAMA/LABA therapy, due to the limited evidence of symptomatic benefit and the significant risk of adverse effects 1

For patients with persistent symptoms and low risk of exacerbations, the guidelines recommend escalating from monotherapy to dual LAMA/LABA therapy 3
For patients with persistent symptoms already on dual therapy, consideration should be given to triple LAMA/LABA/ICS therapy if there is a high risk of exacerbations (≥2 moderate or ≥1 severe exacerbation in the last year) 5
Optimizing pulmonary rehabilitation is the best option for alleviating dyspnea and improving health status, by combining optimal pharmacotherapy with pulmonary rehabilitation 1

The GOLD 2018 guidelines confirm that theophylline is not recommended unless access or affordability of bronchodilators is a problem 2
The availability of safer and more effective long-acting bronchodilators has led to a shift away from theophylline use 2
The superior safety profile of LAMA/LABA therapy has also contributed to the decline in theophylline use 4