Get your patient on Caffeine Citrate - Caffeine Citrate injection (Caffeine Citrate)
Caffeine Citrate - Caffeine Citrate injection prescribing information
INDICATIONS AND USAGE
Caffeine citrate injection is indicated for the treatment of apnea of prematurity.
DOSAGE AND ADMINISTRATION
Prior to initiation of caffeine citrate, baseline serum levels of caffeine should be measured in infants previously treated with theophylline, since preterm infants metabolize theophylline to caffeine. Likewise, baseline serum levels of caffeine should be measured in infants born to mothers who consumed caffeine prior to delivery, since caffeine readily crosses the placenta.
The recommended loading dose and maintenance doses of caffeine citrate follow.
| Dose of caffeine citrate Volume | Dose of caffeine citrate mg/kg | Route | Frequency | |
| Loading Dose | 1 mL/kg | 20 mg/kg | Intravenous• (over 30 minutes) | One Time |
| Maintenance Dose | 0.25 mL/kg | 5 mg/kg | Intravenous• (over 10 minutes) or Orally | Every 24 hours•• |
•Using a syringe infusion pump ••Beginning 24 hours after the loading dose
NOTE THAT THE DOSE OF CAFFEINE BASE IS ONE-HALF THE DOSE WHEN EXPRESSED AS CAFFEINE CITRATE (e.g., 20 mg of caffeine citrate is equivalent to 10 mg of caffeine base).
Serum concentrations of caffeine may need to be monitored periodically throughout treatment to avoid toxicity. Serious toxicity has been associated with serum levels greater than 50 mg/L.
Caffeine citrate should be inspected visually for particulate matter and discoloration prior to administration. Vials containing discolored solution or visible particulate matter should be discarded.
Drug Compatibility
To test for drug compatibility with common intravenous solutions or medications, 20 mL of caffeine citrate injection were combined with 20 mL of a solution or medication, with the exception of an Intralipid ® admixture, which was combined as 80 mL/80 mL. The physical appearance of the combined solutions was evaluated for precipitation. The admixtures were mixed for 10 minutes and then assayed for caffeine. The admixtures were then continually mixed for 24 hours, with further sampling for caffeine assays at 2, 4, 8, and 24 hours.
Based on this testing, caffeine citrate injection USP, 60 mg/3 mL is chemically stable for 24 hours at room temperature when combined with the following test products.
- Dextrose Injection, USP 5%
- 50% Dextrose Injection USP
- Intralipid ® 20% IV Fat Emulsion
- Aminosyn ® 8.5% Crystalline Amino Acid Solution
- Dopamine HCl Injection, USP 40 mg/mL diluted to 0.6 mg/mL with Dextrose Injection, USP 5%.
- Calcium Gluconate Injection, USP 10% (0.465 mEq/Ca +2 /mL)
- Heparin Sodium Injection, USP 1000 units/mL diluted to 1 unit/mL with Dextrose Injection, USP 5%
- Fentanyl Citrate Injection, USP 50 mcg/mL diluted to 10 mcg/mL with Dextrose Injection, USP 5%
CONTRAINDICATIONS
Caffeine citrate injection is contraindicated in patients who have demonstrated hypersensitivity to any of its components.
ADVERSE REACTIONS
Overall, the reported number of adverse events in the double-blind period of the controlled trial was similar for the caffeine citrate and placebo groups. The following table shows adverse events that occurred in the double-blind period of the controlled trial and that were more frequent in caffeine citrate-treated patients than placebo.
ADVERSE EVENTS THAT OCCURRED MORE FREQUENTLY IN CAFFEINE CITRATE INJECTION-TREATED PATIENTS THAN PLACEBO DURING DOUBLE-BLIND THERAPY
| Adverse Event (AE) | Caffeine citrate N=46 n (%) | Placebo N=39 n (%) |
| BODY AS A WHOLE | ||
| Accidental Injury | 1 (2.2) | 0 (0.0) |
| Feeding Intolerance | 4 (8.7) | 2 (5.1) |
| Sepsis | 2 (4.3) | 0 (0.0) |
| CARDIOVASCULAR SYSTEM | ||
| Hemorrhage | 1 (2.2) | 0 (0.0) |
| DIGESTIVE SYSTEM | ||
| Necrotizing Enterocolitis | 2 (4.3) | 1 (2.6) |
| Gastritis | 1 (2.2) | 0 (0.0) |
| Gastrointestinal Hemorrhage | 1 (2.2) | 0 (0.0) |
| HEMIC AND LYMPHATIC SYSTEM | ||
| Disseminated Intravascular Coagulation | 1 (2.2) | 0 (0.0) |
| METABOLIC AND NUTRITIVE DISORDERS | ||
| Acidosis | 1 (2.2) | 0 (0.0) |
| Healing Abnormal | 1 (2.2) | 0 (0.0) |
| NERVOUS SYSTEM | ||
| Cerebral Hemorrhage | 1 (2.2) | 0 (0.0) |
| RESPIRATORY SYSTEM | ||
| Dyspnea | 1 (2.2) | 0 (0.0) |
| Lung Edema | 1 (2.2) | 0 (0.0) |
| SKIN AND APPENDAGES | ||
| Dry Skin | 1 (2.2) | 0 (0.0) |
| Rash | 4 (8.7) | 3 (7.7) |
| Skin Breakdown | 1 (2.2) | 0 (0.0) |
| SPECIAL SENSES | ||
| Retinopathy of Prematurity | 1 (2.2) | 0 (0.0) |
| UROGENITAL SYSTEM | ||
| Kidney Failure | 1 (2.2) | 0 (0.0) |
In addition to the cases above, three cases of necrotizing enterocolitis were diagnosed in patients receiving caffeine citrate during the open-label phase of the study.
Three of the infants who developed necrotizing enterocolitis during the trial died. All had been exposed to caffeine. Two were randomized to caffeine, and one placebo patient was “rescued” with open-label caffeine for uncontrolled apnea.
Adverse events described in the published literature include: central nervous system stimulation (i.e., irritability, restlessness, jitteriness), cardiovascular effects (i.e., tachycardia, increased left ventricular output, and increased stroke volume), gastrointestinal effects (i.e., increased gastric aspirate, gastrointestinal intolerance), alterations in serum glucose (i.e., hypoglycemia and hyperglycemia), and renal effects (i.e., increased urine flow rate, increased creatinine clearance, and increased sodium and calcium excretion). Published long-term follow-up studies have not shown caffeine to adversely affect neurological development or growth parameters.
A published randomized, placebo-controlled, clinical trial in premature infants with birthweights of 500 to 1250 grams studied the safety of caffeine citrate in apnea of prematurity (NCT00182312 ). This trial randomized approximately 2000 premature infants with a mean gestational age of 27 weeks at birth. The median duration of caffeine therapy was 37 days. Prior to discharge home, death, ultrasonographic signs of brain injury, and necrotizing enterocolitis were not more common in the caffeine citrate group compared to the placebo. At follow up at both 18 months and 5 years corrected age, death was not more common in the caffeine citrate treated group compared to placebo, nor did caffeine citrate use adversely affect neurodevelopmental outcomes.
Drug Interactions
Cytochrome P450 1A2 (CYP1A2) is known to be the major enzyme involved in the metabolism of caffeine. Therefore, caffeine has the potential to interact with drugs that are substrates for CYP1A2, inhibit CYP1A2, or induce CYP1A2.
Few data exist on drug interactions with caffeine in preterm neonates. Based on adult data, lower doses of caffeine may be needed following coadministration of drugs which are reported to decrease caffeine elimination (e.g., cimetidine and ketoconazole) and higher caffeine doses may be needed following coadministration of drugs that increase caffeine elimination (e.g., phenobarbital and phenytoin).
Caffeine administered concurrently with ketoprofen reduced the urine volume in four healthy volunteers. The clinical significance of this interaction in preterm neonates is not known.
Interconversion between caffeine and theophylline has been reported in preterm neonates. The concurrent use of these drugs is not recommended.
DESCRIPTION
Caffeine citrate Injection, USP for intravenous administration is clear, colorless, sterile, non-pyrogenic, preservative-free, aqueous solution adjusted to pH 4.7. Each mL contains 20 mg caffeine citrate (equivalent to 10 mg of caffeine base) prepared in solution by the addition of 10 mg caffeine anhydrous to 5 mg citric acid monohydrate, 8.3 mg trisodium citrate dihydrate and Water for Injection.
Caffeine USP, a central nervous system stimulant, is an odorless white crystalline substance or granule, with a bitter taste. It is freely soluble in chloroform, sparingly soluble in water and in alcohol, slightly soluble in ether. The chemical name of caffeine is 3,7-dihydro-1,3,7-trimethyl-1 H-purine-2,6-dione. In the presence of citric acid it forms caffeine citrate salt in solution. The structural formula and molecular weight of caffeine citrate follows.
Caffeine citrate
C 14 H 18 N 4 O 9 MW 386.31
CLINICAL PHARMACOLOGY
Mechanism of Action
Caffeine is structurally related to other methylxanthines, theophylline, and theobromine. It is a bronchial smooth muscle relaxant, a CNS stimulant, a cardiac muscle stimulant, and a diuretic.
Although the mechanism of action of caffeine in apnea of prematurity is not known, several mechanisms have been hypothesized. These include: (1) stimulation of the respiratory center, (2) increased minute ventilation, (3) decreased threshold to hypercapnia, (4) increased response to hypercapnia, (5) increased skeletal muscle tone, (6) decreased diaphragmatic fatigue, (7) increased metabolic rate, and (8) increased oxygen consumption.
Most of these effects have been attributed to antagonism of adenosine receptors, both A 1 and A 2 subtypes, by caffeine, which has been demonstrated in receptor binding assays and observed at concentrations approximating those achieved therapeutically.
Pharmacokinetics
Absorption After oral administration of 10 mg caffeine base/kg to preterm neonates, the peak plasma level (C max ) for caffeine ranged from 6 to 10 mg/L and the mean time to reach peak concentration (T max ) ranged from 30 minutes to 2 hours. The T max was not affected by formula feeding. The absolute bioavailability, however, was not fully examined in preterm neonates.
Distribution Caffeine is rapidly distributed into the brain. Caffeine levels in the cerebrospinal fluid of preterm neonates approximate their plasma levels. The mean volume of distribution of caffeine in infants (0.8 to 0.9 L/kg) is slightly higher than that in adults (0.6 L/kg). Plasma protein binding data are not available for neonates or infants. In adults, the mean plasma protein binding in vitro is reported to be approximately 36%.
Metabolism Hepatic cytochrome P450 1A2 (CYP1A2) is involved in caffeine biotransformation. Caffeine metabolism in preterm neonates is limited due to their immature hepatic enzyme systems.
Interconversion between caffeine and theophylline has been reported in preterm neonates; caffeine levels are approximately 25% of theophylline levels after theophylline administration and approximately 3 to 8% of caffeine administered would be expected to convert to theophylline.
Elimination In young infants, the elimination of caffeine is much slower than that in adults due to immature hepatic and/or renal function. Mean half-life (T 1/2 ) and fraction excreted unchanged in urine (A e ) of caffeine in infants have been shown to be inversely related to gestational/postconceptual age. In neonates, the T 1/2 is approximately 3 to 4 days and the A e is approximately 86% (within 6 days). By 9 months of age, the metabolism of caffeine approximates that seen in adults (T 1/2 = 5 hours and A e = 1%).
Special Populations Studies examining the pharmacokinetics of caffeine in neonates with hepatic or renal insufficiency have not been conducted. Caffeine citrate should be administered with caution in preterm neonates with impaired renal or hepatic function. Serum concentrations of caffeine should be monitored and dose administration of caffeine citrate should be adjusted to avoid toxicity in this population.
Clinical Studies
One multicenter, randomized, double-blind trial compared caffeine citrate to placebo in eighty-five (85) preterm infants (gestational age 28 to <33 weeks) with apnea of prematurity. Apnea of prematurity was defined as having at least 6 apnea episodes of greater than 20 seconds duration in a 24-hour period with no other identifiable cause of apnea. A 1 mL/kg (20 mg/kg caffeine citrate providing 10 mg/kg as caffeine base) loading dose of caffeine citrate was administered intravenously, followed by a 0.25 mL/kg (5 mg/kg caffeine citrate providing 2.5 mg/kg of caffeine base) daily maintenance dose administered either intravenously or orally (generally through a feeding tube). The duration of treatment in this study was limited to 10 to 12 days. The protocol allowed infants to be "rescued" with open-label caffeine citrate treatment if their apnea remained uncontrolled during the double-blind phase of the trial.
The percentage of patients without apnea on day 2 of treatment (24 to 48 hours after the loading dose) was significantly greater with caffeine citrate than placebo. The following table summarizes the clinically relevant endpoints evaluated in this study:
| Caffeine citrate | Placebo | p-value | |
| Number of patients evaluated 1 | 45 | 37 | - |
| % of patients with zero apnea events on day 2 | 26.7 | 8.1 | 0.03 |
| Apnea rate on day 2 (per 24 h) | 4.9 | 7.2 | 0.134 |
| % of patients with 50% reduction in apnea events from baseline on day 2 | 76 | 57 | 0.07 |
1 Of 85 patients who received drug, 3 were not included in the efficacy analysis because they had <6 apnea episodes/24 hours at baseline.
In this 10 to 12 day trial, the mean number of days with zero apnea events was 3 in the caffeine citrate group and 1.2 in the placebo group. The mean number of days with a 50% reduction from baseline in apnea events was 6.8 in the caffeine citrate group and 4.6 in the placebo group.
HOW SUPPLIED
Caffeine citrate injection USP is available as a clear, colorless, sterile, non-pyrogenic, preservative-free, aqueous solution in 3 mL colorless glass vials. The vials are a clear USP Type I 5 mL glass vial with grey chlorobutyl rubber stoppers with white colored, flip off aluminum seals.
The vials contain 3 mL solution at a concentration of 20 mg/mL caffeine citrate (60 mg/vial) equivalent to 10 mg/mL caffeine base (30 mg/vial).
Caffeine citrate Injection USP 60 mg/3 mL is a clear, colorless aqueous solution, individually packaged in a carton and is available as follows.
3 mL fill in 5 mL glass vial
Mono Carton of 5 mL glass vial NDC 72485-104-01
3 mL Single Dose Vial packaged in a carton of 10 NDC 72485-104-10
Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature].
Preservative free. For single use only. Discard unused portion.
To report SUSPECTED ADVERSE REACTIONS, contact Micro Labs USA, Inc. at 1-855-839-8195 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
For Product Inquiry call 1-855-839-8195.
For Intravenous Use Only
Manufactured by: Micro Labs Limited Bangalore-560 099, INDIA.
Distributed by: Armas Pharmaceuticals, Inc. Freehold, NJ 07728 (USA)
Rev. 09/2022
