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Sugino M, Kuboi T, Noguchi Y, Nishioka K, Tadatomo Y, Kawaguchi N, Sadamura T, Nakano A, Konishi Y, Koyano K, Nakamura S, Okada H, Itoh S, Kusaka T. Serum caffeine concentrations in preterm infants: a retrospective study. Sci Rep 2023; 13:10305. [PMID: 37365252 DOI: 10.1038/s41598-023-37544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/23/2023] [Indexed: 06/28/2023] Open
Abstract
Therapeutic drug monitoring is generally unnecessary in caffeine treatment for apnea of prematurity, as serum caffeine concentrations in preterm infants are normally markedly lower than those at which caffeine intoxication occurs. However, several studies have reported preterm infants having developed toxicity. This retrospective observational study, conducted at a tertiary center in Kagawa, Japan, aimed to evaluate the correlation between the maintenance dose and serum caffeine concentrations and determine the maintenance dose leading to suggested toxic caffeine levels. We included 24 preterm infants (gestational age, 27 ± 2.9 weeks; body weight, 991 ± 297 g) who were treated with caffeine citrate for apnea of prematurity between 2018 and 2021, and 272 samples were analyzed. Our primary outcome measure was the maintenance dose leading to suggested toxic caffeine levels. We found a positive correlation between caffeine dose and serum caffeine concentrations (p < 0.05, r = 0.72). At doses of ≥ 8 mg/kg/day, 15% (16/109) of patients had serum caffeine concentrations above the suggested toxic levels. Patients who receive doses ≥ 8 mg/kg/day risk reaching the suggested toxic serum caffeine levels. It remains unclear whether suggested toxic caffeine concentrations are detrimental to neurological prognosis. Further investigation is required to understand the clinical effects/outcomes of high serum levels of caffeine and to obtain long-term neurodevelopmental follow-up data.
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Affiliation(s)
- Masashiro Sugino
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan.
| | - Toru Kuboi
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Yuta Noguchi
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
| | - Katsufumi Nishioka
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Yoko Tadatomo
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Nana Kawaguchi
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Takaaki Sadamura
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Akiko Nakano
- Division of Neonatology, NHO Shikoku Medical Center for Children and Adults, 2-1-1 Senyu Cho, Zentsuji City, Kagawa, 765-8507, Japan
| | - Yukihiko Konishi
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
| | - Kosuke Koyano
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
| | - Shinji Nakamura
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
| | - Hitoshi Okada
- Division of Analytical Technology, Department of Medical Technology, Kagawa Prefectural University of Health Sciences, Takamatsu City, Kagawa, Japan
| | - Susumu Itoh
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kitagun, Kagawa, Japan
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Bruschettini M, Brattström P, Russo C, Onland W, Davis PG, Soll R. Caffeine dosing regimens in preterm infants with or at risk for apnea of prematurity. Cochrane Database Syst Rev 2023; 4:CD013873. [PMID: 37040532 PMCID: PMC10089673 DOI: 10.1002/14651858.cd013873.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Very preterm infants often require respiratory support and are therefore exposed to an increased risk of bronchopulmonary dysplasia (chronic lung disease) and later neurodevelopmental disability. Caffeine is widely used to prevent and treat apnea (temporal cessation of breathing) associated with prematurity and facilitate extubation. Though widely recognized dosage regimes have been used for decades, higher doses have been suggested to further improve neonatal outcomes. However, observational studies suggest that higher doses may be associated with harm. OBJECTIVES To determine the effects of higher versus standard doses of caffeine on mortality and major neurodevelopmental disability in preterm infants with (or at risk of) apnea, or peri-extubation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and clinicaltrials.gov in May 2022. The reference lists of relevant articles were also checked to identify additional studies. SELECTION CRITERIA We included randomized (RCTs), quasi-RCTs and cluster-RCTs, comparing high-dose to standard-dose strategies in preterm infants. High-dose strategies were defined as a high-loading dose (more than 20 mg of caffeine citrate/kg) or a high-maintenance dose (more than 10 mg of caffeine citrate/kg/day). Standard-dose strategies were defined as a standard-loading dose (20 mg or less of caffeine citrate/kg) or a standard-maintenance dose (10 mg or less of caffeine citrate/kg/day). We specified three additional comparisons according to the indication for commencing caffeine: 1) prevention trials, i.e. preterm infants born at less than 34 weeks' gestation, who are at risk for apnea; 2) treatment trials, i.e. preterm infants born at less than 37 weeks' gestation, with signs of apnea; 3) extubation trials: preterm infants born at less than 34 weeks' gestation, prior to planned extubation. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We included seven trials enrolling 894 very preterm infants (reported in Comparison 1, i.e. any indication). Two studies included infants for apnea prevention (Comparison 2), four studies for apnea treatment (Comparison 3) and two for extubation management (Comparison 4); in one study, indication for caffeine administration was both apnea treatment and extubation management (reported in Comparison 1, Comparison 3 and Comparison 4). In the high-dose groups, loading and maintenance caffeine doses ranged from 30 mg/kg to 80 mg/kg, and 12 mg/kg to 30 mg/kg, respectively; in the standard-dose groups, loading and maintenance caffeine doses ranged from 6 mg/kg to 25 mg/kg, and 3 mg/kg to 10 mg/kg, respectively. Two studies had three study groups: infants were randomized in three different doses (two of them matched our definition of high dose and one matched our definition of standard dose); high-dose caffeine and standard-dose caffeine were compared to theophylline administration (the latter is included in a separate review). Six of the seven included studies compared high-loading and high-maintenance dose to standard-loading and standard-maintenance dose, whereas in one study standard-loading dose and high-maintenance dose was compared to standard-loading dose and standard-maintenance dose. High-dose caffeine strategies (administration for any indication) may have little or no effect on mortality prior to hospital discharge (risk ratio (RR) 0.86, 95% confidence of interval (CI) 0.53 to 1.38; risk difference (RD) -0.01, 95% CI -0.05 to 0.03; I² for RR and RD = 0%; 5 studies, 723 participants; low-certainty evidence). Only one study enrolling 74 infants reported major neurodevelopmental disability in children aged three to five years (RR 0.79, 95% CI 0.51 to 1.24; RD -0.15, 95% CI -0.42 to 0.13; 46 participants; very low-certainty evidence). No studies reported the outcome mortality or major neurodevelopmental disability in children aged 18 to 24 months and 3 to 5 years. Five studies reported bronchopulmonary dysplasia at 36 weeks' postmenstrual age (RR 0.75, 95% CI 0.60 to 0.94; RD -0.08, 95% CI -0.15 to -0.02; number needed to benefit (NNTB) = 13; I² for RR and RD = 0%; 723 participants; moderate-certainty evidence). High-dose caffeine strategies may have little or no effect on side effects (RR 1.66, 95% CI 0.86 to 3.23; RD 0.03, 95% CI -0.01 to 0.07; I² for RR and RD = 0%; 5 studies, 593 participants; low-certainty evidence). The evidence is very uncertain for duration of hospital stay (data reported in three studies could not be pooled in meta-analysis because outcomes were expressed as medians and interquartile ranges) and seizures (RR 1.42, 95% CI 0.79 to 2.53; RD 0.14, 95% CI -0.09 to 0.36; 1 study, 74 participants; very low-certainty evidence). We identified three ongoing trials conducted in China, Egypt, and New Zealand. AUTHORS' CONCLUSIONS High-dose caffeine strategies in preterm infants may have little or no effect on reducing mortality prior to hospital discharge or side effects. We are very uncertain whether high-dose caffeine strategies improves major neurodevelopmental disability, duration of hospital stay or seizures. No studies reported the outcome mortality or major neurodevelopmental disability in children aged 18 to 24 months and 3 to 5 years. High-dose caffeine strategies probably reduce the rate of bronchopulmonary dysplasia. Recently completed and future trials should report long-term neurodevelopmental outcome of children exposed to different caffeine dosing strategies in the neonatal period. Data from extremely preterm infants are needed, as this population is exposed to the highest risk for mortality and morbidity. However, caution is required when administering high doses in the first hours of life, when the risk for intracranial bleeding is highest. Observational studies might provide useful information regarding potential harms of the highest doses.
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Affiliation(s)
- Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | | | | | - Wes Onland
- Department of Neonatology, Amsterdam University Medical Centers, VU University Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Caffeine dosing in premature neonates: impact of birth weight on a pharmacokinetic simulation study. Pediatr Res 2023; 93:696-700. [PMID: 35717480 DOI: 10.1038/s41390-022-02172-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal caffeine dosing in extremely premature neonates remains elusive. This study aimed to evaluate the impact of birth weight on caffeine pharmacokinetics and various dosing regimens. METHODS In this pharmacokinetic simulation study, we generated the body weights (0-49 days of postnatal age [PNA]) of neonates <28 weeks gestational age with different birth weights (550, 750, and 1050 g). Their pharmacokinetic parameters were determined based on published pharmacokinetic models. Then, we simulated and compared the caffeine base concentration-time profiles of standard versus off-label caffeine citrate dose regimens. RESULTS The half-life decreased and the weight-adjusted clearance increased more significantly in neonates with lower birth weights, resulting in lower caffeine plasma concentrations. The neonate with the lowest birth weight did not achieve a threshold trough concentration of 15 mg/L after receiving the standard dose (5 mg/kg/day), while the higher-birth-weights (≥750 g) had trough concentrations below the threshold around the second week of life. Higher caffeine doses (10 mg/kg/day) resulted in peak concentrations of <36 mg/L by 10-14 days of PNA while maintaining trough concentrations above 15 mg/L throughout the 49 days PNA. CONCLUSION Higher-than-standard caffeine dosing may be needed for extremely premature neonates, especially for those with lower birth weights. IMPACT Extremely premature neonates with a lower birth weight may require a higher weight-based caffeine dosing due to their higher weight-adjusted clearance and shorter half-lives. Not only do these extremely premature neonates have a higher risk of developing bronchopulmonary dysplasia due to their structurally underdeveloped lungs, but the low birth weight-related underdosing may further contribute to the reduced caffeine effectiveness. Higher-than-standard caffeine citrate dosing (e.g., 10 mg/kg/day maintenance dose) may be needed to further prevent bronchopulmonary dysplasia.
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4
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Miao Y, Zhou Y, Zhao S, Liu W, Wang A, Zhang Y, Li Y, Jiang H. Comparative efficacy and safety of caffeine citrate and aminophylline in treating apnea of prematurity: A systematic review and meta-analysis. PLoS One 2022; 17:e0274882. [PMID: 36121807 PMCID: PMC9484669 DOI: 10.1371/journal.pone.0274882] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Methylxanthine, including caffeine citrate and aminophylline, is the most common pharmacologic treatment for apnea of prematurity. However, due to the lack of high-quality evidence, there are no clear recommendations or guidelines on how to choose between caffeine and aminophylline.
Objective
This meta-analysis aimed to assess the comparative efficacy and safety of caffeine and aminophylline for apnea of prematurity, and provide reliable evidence for clinical medication in the treatment for apnea of prematurity.
Methods
PubMed, Scopus, Embase, EBSCO, Web of Science, and Cochrane databases were systematically searched from May 1975 to June 2022.
Results
Ten studies including a total of 923 preterm infants were evaluated. Our results showed that there was no significant difference in the effective rate of 1-3days between caffeine and aminophylline (OR 1.05, 95%CI: 0.40–2.74, P = 0.914). However, for side effects such as tachycardia (OR 0.22, 95%CI: 0.13–0.37, P<0.001) and feeding intolerance (OR 0.40, 95%CI: 0.23–0.70, P = 0.001), the incidence rate was lower in the caffeine group compared with the aminophylline group. No significant difference was found in hyperglycemia (OR 0.45, 95%CI: 0.19–1.05, P = 0.064).
Conclusion
This meta-analysis reveals that caffeine citrate and aminophylline have similar therapeutic effectiveness on respiratory function, but caffeine has fewer side effects and should be considered first for treatment.
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Affiliation(s)
- Yiqun Miao
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Yun Zhou
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Shuliang Zhao
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Wenwen Liu
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Aihua Wang
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
- * E-mail:
| | - Yuanyuan Zhang
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Yanan Li
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
| | - Huimin Jiang
- School of Nursing, Weifang Medical University, Weifang, Shandong Province, China
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5
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Yuan Y, Yang Y, Lei X, Dong W. Caffeine and bronchopulmonary dysplasia: Clinical benefits and the mechanisms involved. Pediatr Pulmonol 2022; 57:1392-1400. [PMID: 35318830 DOI: 10.1002/ppul.25898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/05/2022] [Accepted: 03/16/2022] [Indexed: 11/06/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease that occurs during the neonatal period and is commonly associated with prematurity. This condition results in a severe economic burden on society and the families involved. Caffeine is used not only for the treatment of apnea in prematurity, but also for the prevention of BPD. There are multiple clinical benefits of caffeine treatment, including improved extubation success, a reduced duration of mechanical ventilation, improved lung function, and a reduction of patent ductus arteriosus requiring treatment. These clinical benefits of caffeine for the treatment of BPD are supported by both clinical trials and evidence from animal models. However, the mechanism by which caffeine protects against BPD remains unclear. Here, we review the clinical value of caffeine in the prevention of BPD and its potential mechanisms of action, including anti-inflammatory, antioxidant, antifibrotic, and antiapoptotic properties, the regulation of angiogenesis, and diuretic effects. Our aim is to provide a new theoretical basis for the clinical treatment of BPD.
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Affiliation(s)
- Yuan Yuan
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yang Yang
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoping Lei
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenbin Dong
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Villanueva-García D, Mota-Rojas D, Miranda-Cortés A, Ibarra-Ríos D, Casas-Alvarado A, Mora-Medina P, Martínez-Burnes J, Olmos-Hernández A, Hernández-Avalos I. Caffeine: cardiorespiratory effects and tissue protection in animal models. Exp Anim 2021; 70:431-439. [PMID: 34039788 PMCID: PMC8614017 DOI: 10.1538/expanim.20-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/20/2021] [Indexed: 10/31/2022] Open
Abstract
The aim of this review is to analyze the cardiorespiratory and tissue-protective effects of caffeine in animal models. Peer-reviewed literature published between 1975 and 2021 was retrieved from CAB Abstracts, PubMed, ISI Web of Knowledge, and Scopus. Extracted data were analyzed to address the mechanism of action of caffeine on cardiorespiratory parameters (heart rate and rhythm), vasopressor effects, and some indices of respiratory function; we close this review by discussing the current debate on the research carried out on the effects of caffeine on tissue protection. Adenosine acts through specific receptors and is a negative inotropic and chronotropic agent. Blockage of its cardiac receptors can cause tachycardia (with arrhythmogenic potential) due to the intense activity of β1 receptors. In terms of tissue protection, caffeine inhibits hyperoxia-induced pulmonary inflammation by decreasing proinflammatory cytokine expression in animal models. The protection that caffeine provides to tissues is not limited to the CNS, as studies have demonstrated that it generates attenuation of inflammatory effects in pulmonary tissue. It inhibits the effects of some pro-inflammatory cytokines and prevents functional and structural changes.
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Affiliation(s)
- Dina Villanueva-García
- Division of Neonatology, National Institute of Health, Hospital Infantil de México Federico Gómez, Doctor Márquez 162, 06720, Mexico City, Mexico
| | - Daniel Mota-Rojas
- Neurophysiology, Behavior, and Animal Welfare Assessment, Department of Animal Production and Agriculture (DPAA), Universidad Autónoma Metropolitana (UAM) Xochimilco Campus, Calzada del Hueso 1100. Col. Villa Quietud. Coyoacán, 04960, Mexico City, Mexico
| | - Agatha Miranda-Cortés
- Clinical Pharmacology and Veterinary Anaesthesia, Department of Biological Science, FESC, Universidad Nacional Autónoma de México (UNAM), Carretera Cuautitlán-Teoloyucan Km. 2.5 San Sebastian Xhala, 54714, Cuautitlán Izcalli, State of Mexico, Mexico
| | - Daniel Ibarra-Ríos
- Division of Neonatology, National Institute of Health, Hospital Infantil de México Federico Gómez, Doctor Márquez 162, 06720, Mexico City, Mexico
| | - Alejandro Casas-Alvarado
- Neurophysiology, Behavior, and Animal Welfare Assessment, Department of Animal Production and Agriculture (DPAA), Universidad Autónoma Metropolitana (UAM) Xochimilco Campus, Calzada del Hueso 1100. Col. Villa Quietud. Coyoacán, 04960, Mexico City, Mexico
| | - Patricia Mora-Medina
- Livestock Science Department, Universidad Nacional Autónoma de México (UNAM), Facultad de Estudios Superiores Cuautitlán, Carretera Cuautitlán-Teoloyucan Km. 2.5 San Sabastian Xhala, 54714, Cuautitlán Izcalli, State of Mexico, Mexico
| | - Julio Martínez-Burnes
- Graduate and Research Department, Facultad de Medicina Veterinaria y Zootecnia, Universidad Autónoma de Tamaulipas, Km 5 Carretera Victoria-Mante, 87000, Cd. Victoria, Tamaulipas, Mexico
| | - Adriana Olmos-Hernández
- Division of Biotechnology, Department Bioterio and Experimental Surgery. Instituto Nacional de Rehabilitación-Luis Guillermo Ibarra Ibarra (INR-LGII), Calzada México Xochimilco, 289, 14389, Mexico City, Mexico
| | - Ismael Hernández-Avalos
- Clinical Pharmacology and Veterinary Anaesthesia, Department of Biological Science, FESC, Universidad Nacional Autónoma de México (UNAM), Carretera Cuautitlán-Teoloyucan Km. 2.5 San Sebastian Xhala, 54714, Cuautitlán Izcalli, State of Mexico, Mexico
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7
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Long JY, Guo HL, He X, Hu YH, Xia Y, Cheng R, Ding XS, Chen F, Xu J. Caffeine for the Pharmacological Treatment of Apnea of Prematurity in the NICU: Dose Selection Conundrum, Therapeutic Drug Monitoring and Genetic Factors. Front Pharmacol 2021; 12:681842. [PMID: 34381359 PMCID: PMC8350115 DOI: 10.3389/fphar.2021.681842] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/12/2021] [Indexed: 12/20/2022] Open
Abstract
Caffeine citrate is the drug of choice for the pharmacological treatment of apnea of prematurity. Factors such as maturity and genetic variation contribute to the interindividual variability in the clinical response to caffeine therapy in preterm infants, making the optimal dose administered controversial. Moreover, the necessity for therapeutic drug monitoring (TDM) of caffeine is still worth discussing due to the need to achieve the desired target concentrations as well as concerns about the safety of higher doses. Therefore, we reviewed the pharmacokinetic profile of caffeine in preterm infants, evidence of the safety and efficacy of different doses of caffeine, therapeutic concentration ranges of caffeine and impact of genetic variability on caffeine therapy. Whereas the safety and efficacy of standard-dose caffeine have been demonstrated, evidence for the safety of higher administered doses is insufficient. Thus, preterm infants who lack clinical response to standard-dose caffeine therapy are of interest for TDM when dose optimization is performed. Polymorphisms in pharmacodynamics-related genes, but not in pharmacokinetics-related genes, have a significant impact on the interindividual variability in clinical response to caffeine therapy. For preterm infants lacking clinical response, how to develop individualized medication regimens for caffeine remains to be explored.
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Affiliation(s)
- Jia-Yi Long
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xin He
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Xia
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Cheng
- Neonatal Intensive Care Unit, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuan-Sheng Ding
- School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
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8
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Faramarzi F, Shiran M, Rafati M, Farhadi R, Salehifar E, Nakhshab M. Prediction of pharmacokinetic values of two various dosages of caffeine in premature neonates with apnea. Indian J Pharmacol 2021; 53:108-114. [PMID: 34100394 PMCID: PMC8265417 DOI: 10.4103/ijp.ijp_504_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite extensive caffeine use in preterm infants, the pharmacokinetics (PKs) data are limited because of the studies are complicated to do in these patients. This research was investigated the PK profile of two various dosages of caffeine in premature neonates. MATERIALS AND METHODS The PK values of caffeine in premature neonates with Apnea were predicted by using all of computer-based simulation (Simcyp®), population-based PK, and modeling (P-Pharm®). We assayed the plasma levels of caffeine in two groups. The information was analyzed utilizing nonlinear mixed-effects modeling approach. The PK parameters were assessed simulating virtual clinical considers with subjects got 20 mg. kg-1 of caffeine in both groups, which was followed by a 5 mg. kg-1 once daily in Group 1 or 2.5 mg. kg-1 twice daily in Group 2. All statistical analysis was executed utilizing SSPS issue 19 and a P value of 0.05 was chosen significance. RESULTS In the present study, the means CL, volume of distribution, and T1/2 of caffeine in preterm infants were 0.0476 L. h-1, 1.1081 L, 16.2284 h, respectively. Whereas our simulated means by Simcyp were 0.090 L. h-1, 1.841 L, and 14.653 h in Group 1 and 16.223 h in Group 2, respectively. CONCLUSIONS There was overall good agreement between predicted and measured PK values in our study. This study provides an initial demonstration of Simcyp simulation advantage on anticipating of PK parameters.
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Affiliation(s)
- Fatemeh Faramarzi
- Clinical Pharmacy Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Shiran
- Immunogenetics Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammadreza Rafati
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Roya Farhadi
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Salehifar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Nakhshab
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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9
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Bruschettini M, Brattström P, Russo C, Onland W, Davis PG, Soll R. Caffeine dosing regimens in preterm infants with or at risk for apnea of prematurity. Hippokratia 2021. [DOI: 10.1002/14651858.cd013873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
| | | | | | - Wes Onland
- Department of Neonatology; Amsterdam University Medical Centers, VU University Medical Center, Emma Children's Hospital, University of Amsterdam; Amsterdam Netherlands
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services; The Royal Women’s Hospital; Melbourne Australia
- Murdoch Children's Research Institute; Melbourne Australia
- Department of Obstetrics and Gynecology; University of Melbourne; Melbourne Australia
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Larner College of Medicine at the University of Vermont; Burlington Vermont USA
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10
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Saroha V, Patel RM. Caffeine for preterm infants: Fixed standard dose, adjustments for age or high dose? Semin Fetal Neonatal Med 2020; 25:101178. [PMID: 33168464 PMCID: PMC8096613 DOI: 10.1016/j.siny.2020.101178] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Caffeine is an effective treatment for apnea of prematurity and has several important benefits, including decreasing respiratory morbidity and motor impairment. In this article, we focus on the dose of caffeine. We review the evidence regarding the efficacy and safety of standard caffeine dosing and alternative dosing approaches, including the use of high dose caffeine and routine dose adjustments for age. Current evidence suggests high dose caffeine may provide additional benefit in reducing the risk of bronchopulmonary dysplasia and extubation failure, but may also increase the risk of cerebellar hemorrhage and seizures. Increasing the standard caffeine citrate dose every 1-2 weeks to a goal dose of 8 mg per kilogram every 24 h may help maintain therapeutic effect. We conclude by highlighting the need for additional trials before high dose caffeine is routinely used.
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Affiliation(s)
- Vivek Saroha
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, Division of Neonatology, Atlanta, GA, 30322, USA.
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, Division of Neonatology, Atlanta, GA, 30322, USA.
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11
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De Rose DU, Cairoli S, Dionisi M, Santisi A, Massenzi L, Goffredo BM, Dionisi-Vici C, Dotta A, Auriti C. Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age. Int J Mol Sci 2020; 21:E5898. [PMID: 32824472 PMCID: PMC7460644 DOI: 10.3390/ijms21165898] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Sara Cairoli
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Marco Dionisi
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Luca Massenzi
- Neonatal Intensive Care Unit and Neonatal Pathology, Fatebenefratelli Hospital, 00186 Rome, Italy;
| | - Bianca Maria Goffredo
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Carlo Dionisi-Vici
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
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12
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Chung J, Tran Lopez K, Amendolia B, Bhat V, Nakhla T, Slater-Myer L, Saslow J, Aghai ZH. Stopping caffeine in premature neonates: how long does it take for the level of caffeine to fall below the therapeutic range? J Matern Fetal Neonatal Med 2020; 35:551-555. [PMID: 32079435 DOI: 10.1080/14767058.2020.1729117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Caffeine is routinely used in preterm infants for apnea of prematurity. Preterm infants are usually monitored for 5 days after discontinuation of caffeine to assess for possible recurrence of apnea. Our objective was to determine if the serum concentration of caffeine decreases to a subtherapeutic level 5 days after its discontinuation.Methods: This is a retrospective analysis of caffeine levels after the drug was discontinued in preterm neonates (birth weight ≤1500 g) born between January 2010 and June 2017. The primary outcome was the proportion of infants with therapeutic levels of caffeine 5 days after the drug was stopped.Results: Caffeine levels were measured in 353 samples from 280 infants (birth weight 1246 ± 390 g and gestational age 29.2 ± 2.4 weeks) after discontinuation of the drug. Five and more days after discontinuation of caffeine, 29.3% (82/280) of the infants had caffeine levels ≥5 mg/L. Approximately 41% (75/181) of the caffeine levels measured between 5 and 7 days and 18% (17/95) between 8 and 10 days were ≥5 mg/L. A caffeine dose of >5 mg/kg/day when discontinued was associated with the caffeine level of ≥5 mg/L (OR 2.3, 95% CI 1.28-4.13, p = .005).Conclusions: Preterm infants treated with caffeine frequently had therapeutic levels of caffeine 5-10 days after discontinuation of the drug. The infants receiving higher doses were more likely to have a therapeutic level of caffeine 5 days after stopping the medication. Preterm infants should be monitored for recurrence of apnea for more than 5 days after stopping caffeine or levels should be monitored prior to discharge.
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Affiliation(s)
- Jane Chung
- Division of Pediatrics/Neonatology, Tufts Medical Center, Boston, MA, USA
| | - Kim Tran Lopez
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Barbara Amendolia
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Vishwanath Bhat
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Tarek Nakhla
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Linda Slater-Myer
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Judy Saslow
- Division of Pediatrics/Neonatology, Cooper University Hospital, Camden, NJ, USA
| | - Zubair H Aghai
- Division of Pediatrics/Neonatology, Thomas Jefferson University, Philadelphia, PA, USA
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13
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Moschino L, Zivanovic S, Hartley C, Trevisanuto D, Baraldi E, Roehr CC. Caffeine in preterm infants: where are we in 2020? ERJ Open Res 2020; 6:00330-2019. [PMID: 32154294 PMCID: PMC7049734 DOI: 10.1183/23120541.00330-2019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022] Open
Abstract
The incidence of preterm birth is increasing, leading to a growing population with potential long-term pulmonary complications. Apnoea of prematurity (AOP) is one of the major challenges when treating preterm infants; it can lead to respiratory failure and the need for mechanical ventilation. Ventilating preterm infants can be associated with severe negative pulmonary and extrapulmonary outcomes, such as bronchopulmonary dysplasia (BPD), severe neurological impairment and death. Therefore, international guidelines favour non-invasive respiratory support. Strategies to improve the success rate of non-invasive ventilation in preterm infants include pharmacological treatment of AOP. Among the different pharmacological options, caffeine citrate is the current drug of choice. Caffeine is effective in reducing AOP and mechanical ventilation and enhances extubation success; it decreases the risk of BPD; and is associated with improved cognitive outcome at 2 years of age, and pulmonary function up to 11 years of age. The commonly prescribed dose (20 mg·kg-1 loading dose, 5-10 mg·kg-1 per day maintenance dose) is considered safe and effective. However, to date there is no commonly agreed standardised protocol on the optimal dosing and timing of caffeine therapy. Furthermore, despite the wide pharmacological safety profile of caffeine, the role of therapeutic drug monitoring in caffeine-treated preterm infants is still debated. This state-of-the-art review summarises the current knowledge of caff-eine therapy in preterm infants and highlights some of the unresolved questions of AOP. We speculate that with increased understanding of caffeine and its metabolism, a more refined respiratory management of preterm infants is feasible, leading to an overall improvement in patient outcome.
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Affiliation(s)
- Laura Moschino
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | - Sanja Zivanovic
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Dept of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Eugenio Baraldi
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Dept of Paediatrics, University of Oxford, Oxford, UK
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Brattström P, Russo C, Ley D, Bruschettini M. High-versus low-dose caffeine in preterm infants: a systematic review and meta-analysis. Acta Paediatr 2019; 108:401-410. [PMID: 30242903 DOI: 10.1111/apa.14586] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 06/26/2018] [Accepted: 09/18/2018] [Indexed: 12/13/2022]
Abstract
AIM Though caffeine is a consolidated treatment in preterm infants, the efficacy and safety of a higher dose have not been systematically appraised. METHODS A systematic review was conducted to compare high (loading dose >20 mg/kg and maintenance >10 mg/kg/day) versus low dose of caffeine. MEDLINE, EMBASE, Central and conference proceedings for randomised controlled trials (RCTs) and quasi-RCTs were searched. Two authors independently screened the records, extracted the data and assessed the risk of bias. RESULTS As only six RCTs enrolling a total of 816 preterm infants were included, the required information size was not reached. The loading and maintenance doses varied between 20 and 80 mg/kg/day and 3 and 20 mg/kg/day, respectively. The use of high dose had no impact on mortality (RR: 0.85; 95% CI: 0.53-1.38; RCTs = 4). However, it resulted in fewer cases of extubation failure, apnoeas and bronchopulmonary dysplasia (RR: 0.76; 95% CI: 0.60-0.96; studies = 4) and shorter duration of mechanical ventilation. The quality of the evidence was low due to imprecision of the estimates. CONCLUSION Due to imprecision, it is not possible to determine whether high-dose caffeine is more effective and safe than a low dose. High dose might improve short-term respiratory function and reduce bronchopulmonary dysplasia.
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Affiliation(s)
| | | | - David Ley
- Department of Paediatrics Lund University Skåne University Hospital Lund Sweden
| | - Matteo Bruschettini
- Department of Paediatrics Lund University Skåne University Hospital Lund Sweden
- Cochrane Sweden Lund Sweden
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15
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Ravichandran S, Chouthai NS, Patel B, Sharma A, Gupte A, Ma MM, Mamilla D, Lulic‐Botica M, Thomas R, Kamat D. Higher daily doses of caffeine lowered the incidence of moderate to severe neurodevelopmental disabilities in very low birth weight infants. Acta Paediatr 2019; 108:430-435. [PMID: 29920770 DOI: 10.1111/apa.14465] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/15/2018] [Indexed: 12/24/2022]
Abstract
AIM We determined the influence of cumulative dosing of caffeine citrate on the neurodevelopmental outcomes of low birth weight (VLBW) infants at 18-22 months of postmenstrual age. METHODS This retrospective chart analysis was conducted at Detroit Medical Center, Michigan, USA. The 181 infants we included were born between January 2006 and December 2016, were less than 32 weeks of gestational age and weighed less than 1500 grams. Data on their perinatal and postnatal characteristics were retrieved from their medical records and they were assessed using the Bayley Scales of Infant Development - Third Edition. RESULTS The 64 infants with no neurodevelopmental disability or a mild disability received a significantly higher average daily dose (mg/kg/day) of caffeine citrate with a median of 7.58 (range 2.7-12.2) mg/kg/day, than the 79 infants with a moderate to severe disability, who received a median of 6.47 (range 3.1-12.5, p = 0.01). The total cumulative dose had no effect on bronchopulmonary dysplasia or neurodevelopmental outcomes. CONCLUSION A higher average daily dose of caffeine citrate was associated with better neurodevelopmental outcomes of VLBW infants. However, the cumulative dose did not have an impact on their short-term or long-term outcomes. Further research is needed to confirm our findings.
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Affiliation(s)
- Saranya Ravichandran
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Nitin Shashikant Chouthai
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
- Division of Neonatal‐Perinatal Medicine Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Bhavyata Patel
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Amit Sharma
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Avanti Gupte
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Mia Michelle Ma
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Divya Mamilla
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | | | - Ronald Thomas
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
| | - Deepak Kamat
- Carman and Ann Adams Department of Pediatrics Wayne State University Detroit MI USA
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16
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Ye C, Miao C, Yu L, Dong Z, Zhang J, Mao Y, Lu X, Lyu Q. Factors affecting the efficacy and safety of aminophylline in treatment of apnea of prematurity in neonatal intensive care unit. Pediatr Neonatol 2019; 60:43-49. [PMID: 29673564 DOI: 10.1016/j.pedneo.2018.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/12/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND The factors affecting the safety and efficacy of aminophylline use in the treatment of apnea of prematurity (AOP) in the neonatal intensive care unit (NICU) are not clear. In this study, we aimed to evaluate the potential factors affecting the efficacy and safety of aminophylline in AOP treatment at standard doses and to determine appropriate patients for this therapy. METHODS Over a 3-year period (January 2012 to December 2014), the medical records of 206 preterm infants with apnea who were admitted to the NICU of our hospital to receive aminophylline infusions were retrospectively reviewed. These infants were subjected to routine theophylline monitoring by reversed-phase high performance liquid chromatography. The primary outcome measures were the efficacy of aminophylline treatment and adverse reactions observed upon administration. RESULTS One-hundred and twenty-seven (61.65%) infants were considered to have undergone effective therapy and classified accordingly. Gestational age, body weight at the initiation of aminophylline, and serum theophylline concentration were identified as protective factors of therapeutic efficacy. Receiver operating characteristic (ROC) analysis indicated cutoff values of 30.36 weeks for gestational age and 1.69 kg for body weight at initiation of aminophylline administration for ensuring high efficacy of aminophylline for AOP. Fifty-three (25.73%) infants had adverse reactions. Birth weight and serum concentration of theophylline were associated with an increased risk of adverse reactions, with odds ratios of 0.167 and 1.346, respectively. The ROC curves indicated a birth weight cutoff value of 1.48 kg. CONCLUSION Infants with apnea and gestational age >30.36 weeks, body weight at initiation of aminophylline treatment above 1.69 kg, and birth weight >1.48 kg are suitable for treatment with aminophylline. Monitoring of serum theophylline concentration should be implemented in the absence of clinical response or in case of suspected adverse reactions.
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Affiliation(s)
- Chaohui Ye
- Department of Pharmacy, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Caiyun Miao
- Department of Pharmacy, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Li Yu
- Department of Pharmacy, The Affiliated Hospital of Medical School of Ningbo University, Ningbo 315020, Zhejiang, China
| | - Zhuoya Dong
- Department of Neonatal Intensive Care Unit, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Jie Zhang
- Department of Pharmacy, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Yingying Mao
- Department of Pharmacy, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Xiaodong Lu
- Department of Pharmacy, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China
| | - Qin Lyu
- Department of Neonatal Intensive Care Unit, Ningbo Women & Children Hospital, Ningbo 315012, Zhejiang, China.
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17
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Caffeine: an evidence-based success story in VLBW pharmacotherapy. Pediatr Res 2018; 84:333-340. [PMID: 29983414 DOI: 10.1038/s41390-018-0089-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 03/22/2018] [Accepted: 04/14/2018] [Indexed: 01/01/2023]
Abstract
Apnea of prematurity (AOP) is a common and pervasive problem in very low birth weight infants. Methylxanthines were reported >40 years ago to be an effective therapy and, by the early 2000s, caffeine had become the preferred methylxanthine because of its wide therapeutic index, excellent bioavailability, and longer half-life. A clinical trial to address unresolved questions and toxicity concerns, completed in 2004, confirmed significant benefits of caffeine therapy, including shorter duration of intubation and respiratory support, reduced incidence of chronic lung disease, decreased need for treatment of patent ductus arteriosus, reduced severity of retinopathy of prematurity, and improved motor and visual function. Cohort studies have now further delineated the benefits of initiation of therapy before 3 days postnatal age, and of higher maintenance doses to achieve incremental beneficial effects. This review summarizes the pivotal and in particular the most recent studies that have established the safety and efficacy of caffeine therapy for AOP and other respiratory and neurodevelopmental outcomes. Caffeine has a very favorable benefit-to-risk ratio, and has become one of the most prescribed and cost-effective pharmacotherapies in the NICU.
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18
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Shenk EE, Bondi DS, Pellerite MM, Sriram S. Evaluation of Timing and Dosing of Caffeine Citrate in Preterm Neonates for the Prevention of Bronchopulmonary Dysplasia. J Pediatr Pharmacol Ther 2018; 23:139-145. [PMID: 29720916 DOI: 10.5863/1551-6776-23.2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the timing and dosing of caffeine therapy in relation to the development of bronchopulmonary dysplasia (BPD). METHODS This was a single-center, retrospective cohort study comparing early (days of life 0-2) to late (day of life 3 or greater) caffeine initiation in extremely low birth weight neonates, with a secondary analysis of large (10 mg/kg/day) to small dose (5 mg/kg/day) caffeine. RESULTS There were 138 patients in the primary timing analysis. The early caffeine group had a lower incidence and reduced odds of the composite outcome of BPD or all-cause mortality, compared with the late caffeine group (64% vs. 88%, respectively; adjusted p < 0.05; adjusted OR 0.36 [95% CI 0.13-0.98]). No statistically significant difference was found between dosing groups (p = 0.29) in the primary outcome; however, there was a lower rate of patent ductus arteriosus requiring treatment (p = 0.05) and decreased likelihood of discharging home on oxygen (p = 0.02) in the large-dose group compared with the small-dose group. CONCLUSIONS Early caffeine initiation significantly decreased the incidence of BPD or all-cause mortality in extremely low birth weight neonates. Patients receiving large-dose caffeine had improved secondary outcomes, although no difference in BPD was noted. Further studies are needed to determine the optimal dosing of caffeine.
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19
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Caffeine Citrate Dosing Adjustments to Assure Stable Caffeine Concentrations in Preterm Neonates. J Pediatr 2017; 191:50-56.e1. [PMID: 29173321 DOI: 10.1016/j.jpeds.2017.08.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/06/2017] [Accepted: 08/23/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To identify dosing strategies that will assure stable caffeine concentrations in preterm neonates despite changing caffeine clearance during the first 8 weeks of life. METHODS A 3-step simulation approach was used to compute caffeine doses that would achieve stable caffeine concentrations in the first 8 weeks after birth: (1) a mathematical weight change model was developed based on published weight distribution data; (2) a pharmacokinetic model was developed based on published models that accounts for individual body weight, postnatal, and gestational age on caffeine clearance and volume of distribution; and (3) caffeine concentrations were simulated for different dosing regimens. RESULTS A standard dosing regimen of caffeine citrate (using a 20 mg/kg loading dose and 5 mg/kg/day maintenance dose) is associated with a maximal trough caffeine concentration of 15 mg/L after 1 week of treatment. However, trough concentrations subsequently exhibit a clinically relevant decrease because of increasing clearance. Model-based simulations indicate that an adjusted maintenance dose of 6 mg/kg/day in the second week, 7 mg/kg/day in the third to fourth week and 8 mg/kg/day in the fifth to eighth week assures stable caffeine concentrations with a target trough concentration of 15 mg/L. CONCLUSIONS To assure stable caffeine concentrations during the first 8 weeks of life, the caffeine citrate maintenance dose needs to be increased by 1 mg/kg every 1-2 weeks. These simple adjustments are expected to maintain exposure to stable caffeine concentrations throughout this important developmental period and might enhance both the short- and long-term beneficial effects of caffeine treatment.
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20
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Tabacaru CR, Jang SY, Patel M, Davalian F, Zanelli S, Fairchild KD. Impact of Caffeine Boluses and Caffeine Discontinuation on Apnea and Hypoxemia in Preterm Infants. JOURNAL OF CAFFEINE RESEARCH 2017; 7:103-110. [PMID: 28875061 DOI: 10.1089/jcr.2017.0002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Apnea of prematurity often occurs during and following caffeine therapy. We hypothesized that number of apnea events would be impacted by adjustments in caffeine therapy. Materials and Methods: An automated algorithm was used in all infants ≤32 weeks gestation admitted to a level IV Neonatal Intensive Care Unit from 2009 to 2014 to analyze chest impedance, electrocardiogram, and oxygen saturation data around the time of serum caffeine levels, caffeine boluses while on maintenance therapy, and caffeine discontinuation. Episodes of central apnea/bradycardia/desaturation (ABDs), and percent time with SpO2 <88% and <75% were measured. Results: ABDs were analyzed in 302 preterm infants (mean gestational age 27.6 weeks) around the time of 485 serum caffeine levels, 90 caffeine boluses, and 273 episodes of caffeine discontinuation. Higher serum caffeine levels were not associated with fewer ABDs or higher heart rate. For caffeine boluses given due to clinically recognized spells, hypoxemia and algorithm-detected ABDs decreased day 1-2 after the bolus compared to the day before and day of the bolus (mean 4.4 events/day after vs. 6.6 before, p = 0.004). After caffeine discontinuation, there was no change in hypoxemia and a small increase in ABDs (2 events/day 3-5 days after discontinuation vs. 1 event/day before and >5 days after, p < 0.01). This increase in ABDs occurred irrespective of gestational age, respiratory support, or postmenstrual age at the time caffeine was stopped. Conclusions: In this retrospective analysis, caffeine boluses and caffeine discontinuation were associated with a small change in the number of ABD events in preterm infants.
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Affiliation(s)
- Christa R Tabacaru
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Suk Young Jang
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Manisha Patel
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Faranek Davalian
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Santina Zanelli
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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21
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Abstract
Caffeine is one of the most commonly prescribed medications in preterm neonates and is widely used to treat or prevent apnea of prematurity. Caffeine therapy is safe, effectively decreases apnea, and improves short- and long-term outcomes in preterm infants. In this review, the authors summarize the role of caffeine therapy for preterm infants receiving noninvasive respiratory support. As caffeine is already widely used, recent data are summarized that may guide clinicians in optimizing the use of caffeine therapy, with a review of the timing of initiation, dose, and duration of therapy.
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Affiliation(s)
- Nicole R. Dobson
- Department of Pediatrics, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859. Tel 808-433-6534.
| | - Ravi Mangal Patel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA.
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Abstract
AIM DBS might be an appropriate microsampling technique for therapeutic drug monitoring of caffeine in infants. Nevertheless, its application presents several issues that still limit its use. This paper describes a validated DBS-LC-MS/MS method for caffeine. RESULTS The results of the method validation showed an hematocrit dependence. In the analysis of 96 paired plasma and DBS clinical samples, caffeine levels measured in DBS were statistically significantly lower than in plasma but the observed differences were independent from hematocrit. CONCLUSION These results clearly showed the need for extensive validation with real-life samples for DBS-based methods. DBS-LC-MS/MS can be considered to be a good alternative to traditional methods for therapeutic drug monitoring or PK studies in preterm infants.
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Morton SU, Smith VC. Treatment options for apnoea of prematurity. Arch Dis Child Fetal Neonatal Ed 2016; 101:F352-6. [PMID: 27010019 DOI: 10.1136/archdischild-2015-310228] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/26/2016] [Indexed: 12/29/2022]
Abstract
Apnoea of prematurity (AOP) affects almost all infants born at <28 weeks gestation or with birth weight <1000 g. When untreated, AOP may be associated with negative outcomes. Because of these negative outcomes, effective treatment for AOP is an important part of optimising care of preterm infants. Standard treatment usually involves xanthine therapy and respiratory support. Cutting-edge work with stochastic vibrotactile stimulation and new pharmaceutical agents continues to expand therapeutic options. In this article, we review the pathophysiology of AOP, associated conditions and treatment options.
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Affiliation(s)
- Sarah U Morton
- Harvard Neonatal-Perinatal Fellowship Program, Boston Children's Hospital Boston, Boston, Massachusetts, USA
| | - Vincent C Smith
- Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Dobson NR, Liu X, Rhein LM, Darnall RA, Corwin MJ, McEntire BL, Ward RM, James LP, Sherwin CMT, Heeren TC, Hunt CE. Salivary caffeine concentrations are comparable to plasma concentrations in preterm infants receiving extended caffeine therapy. Br J Clin Pharmacol 2016; 82:754-61. [PMID: 27145974 DOI: 10.1111/bcp.13001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/05/2016] [Accepted: 04/30/2016] [Indexed: 12/24/2022] Open
Abstract
AIMS Caffeine concentrations in preterm infants are usually measured in the blood. However, salivary assays may provide a valid and practical alternative. The present study explored the validity and clinical utility of salivary caffeine concentrations as an alternative to blood concentrations and developed a novel plasma/salivary caffeine distribution model. METHODS Paired salivary and plasma samples were obtained in 29 infants. Salivary samples were obtained using a commercially available salivary collection system. Caffeine concentrations in the saliva and plasma were determined using high-performance liquid chromatography. A population pharmacokinetic (PK) model was developed using NONMEM 7.3. RESULTS The mean (± standard deviation) gestational age (GA) at birth and birth weight were 27.9 ± 2.1 weeks and 1171.6 ± 384.9 g, respectively. Paired samples were obtained at a mean postmenstrual age (PMA) of 35.5 ± 1.1 weeks. The range of plasma caffeine concentrations was 9.5-54.1 μg ml(-1) , with a mean difference (95% confidence interval) between plasma and salivary concentrations of -0.18 μg ml(-1) (-1.90, 1.54). Salivary and plasma caffeine concentrations were strongly correlated (Pearson's correlation coefficient = 0.87, P < 0.001). Caffeine PK in plasma and saliva was simultaneously described by a three-compartment recirculation model. Current body weight, birth weight, GA, PMA and postnatal age were not significantly correlated with any PK parameter. CONCLUSIONS Salivary sampling provides an easy, non-invasive method for measuring caffeine concentrations. Salivary concentrations correlate highly with plasma concentrations. Caffeine PK in saliva and plasma are well described by a three-compartment recirculation model.
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Affiliation(s)
- Nicole R Dobson
- Pediatrics, Tripler Army Medical Center, Honolulu, HI, USA.,Pediatrics, Uniformed Services University, Bethesda, MD, USA
| | - Xiaoxi Liu
- Clinical Pharmacology, Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lawrence M Rhein
- Newborn Medicine and Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | | | | | | | - Robert M Ward
- Clinical Pharmacology, Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Laura P James
- Pediatrics, University of Arkansas, Little Rock, AR, USA
| | - Catherine M T Sherwin
- Clinical Pharmacology, Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Timothy C Heeren
- Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Carl E Hunt
- Pediatrics, Uniformed Services University, Bethesda, MD, USA.,Pediatrics, George Washington University, Washington, DC, USA
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25
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Affiliation(s)
- Doron J Kahn
- Neonatologist, Assistant Medical Director, Joe DiMaggio Children's Hospital, Hollywood, Florida
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26
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Hütten MC, Wolfs TGAM, Kramer BW. Can the preterm lung recover from perinatal stress? Mol Cell Pediatr 2016; 3:15. [PMID: 27075524 PMCID: PMC4830776 DOI: 10.1186/s40348-016-0043-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
After birth, adequate lung function is necessary for the successful adaptation of a preterm baby. Both prenatal and postnatal insults and therapeutic interventions have an immediate effect on lung function and gas exchange but also interfere with fetal and neonatal lung development. Prenatal insults like chorioamnionitis and prenatal interventions like maternal glucocorticosteroids interact but might also determine the preterm baby's lung response to postnatal interventions ("second hit") like supplementation of oxygen and drug therapy. We review current experimental and clinical findings on the influence of different perinatal factors on preterm lung development and discuss how well-established interventions in neonatal care might be adapted to attenuate postnatal lung injury.
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Affiliation(s)
- Matthias C Hütten
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands.,Neonatology, Department of Pediatrics, Aachen University Hospital, Aachen, Germany.,Neonatology, Department of Pediatrics, Würzburg University Hospital, Würzburg, Germany.,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Tim G A M Wolfs
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands.,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Boris W Kramer
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands. .,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
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Apnea of prematurity and caffeine pharmacokinetics: potential impact on hospital discharge. J Perinatol 2016; 36:141-4. [PMID: 26562367 DOI: 10.1038/jp.2015.167] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/02/2015] [Accepted: 10/07/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the half-life of serum caffeine concentrations and its relation to apnea of prematurity (AOP) after caffeine is discontinued in preparation for hospital discharge. STUDY DESIGN Prospective cohort study involving preterm infants with gestational ages ⩽33 weeks at birth. After caffeine was discontinued, serum caffeine concentrations and electronic detection of pathologic apnea, defined a priori, were obtained at 24 and 168 h, respectively. RESULT Caffeine levels decreased from 13.3±3.8 to 4.3±2 mg l(-1) (n=50, mean±s.d.) at 24 and 168 h, respectively (P<0.01). The mean caffeine half-life was 87±25 h at 35±1 weeks postmenstrual age. Seven days after discontinuation of caffeine, 64% of the infants had pathologic apnea. CONCLUSION Hospital discharge planning for preterm infants with a history of AOP should be carefully considered after discontinuing caffeine. This study showed that caffeine may not reach subtherapeutic levels until around 11-12 days.
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