NDC 63323-407 Caffeine Citrate

Caffeine Citrate

NDC Product Code 63323-407

NDC 63323-407-03

Package Description: 1 VIAL in 1 BOX > 3 mL in 1 VIAL

NDC 63323-407-04

Package Description: 1 VIAL in 1 BOX > 3 mL in 1 VIAL

NDC Product Information

Caffeine Citrate with NDC 63323-407 is a a human prescription drug product labeled by Fresenius Kabi Usa, Llc. The generic name of Caffeine Citrate is caffeine citrate. The product's dosage form is injection, solution and is administered via intravenous form. The RxNorm Crosswalk for this NDC code indicates a single RxCUI concept is associated to this product: 849931.

Dosage Form: Injection, Solution - A liquid preparation containing one or more drug substances dissolved in a suitable solvent or mixture of mutually miscible solvents that is suitable for injection.

Product Type: Human Prescription Drug What kind of product is this?
Indicates the type of product, such as Human Prescription Drug or Human Over the Counter Drug. This data element matches the “Document Type” field of the Structured Product Listing.

Caffeine Citrate Active Ingredient(s)

What is the Active Ingredient(s) List?
This is the active ingredient list. Each ingredient name is the preferred term of the UNII code submitted.


Inactive Ingredient(s)

About the Inactive Ingredient(s)
The inactive ingredients are all the component of a medicinal product OTHER than the active ingredient(s). The acronym "UNII" stands for “Unique Ingredient Identifier” and is used to identify each inactive ingredient present in a product.

  • SODIUM CITRATE (UNII: 1Q73Q2JULR)
  • CITRIC ACID MONOHYDRATE (UNII: 2968PHW8QP)

Administration Route(s)

What are the Administration Route(s)?
The translation of the route code submitted by the firm, indicating route of administration.

  • Intravenous - Administration within or into a vein or veins.
  • Intravenous - Administration within or into a vein or veins.

Pharmacological Class(es)

What is a Pharmacological Class?
These are the reported pharmacological class categories corresponding to the SubstanceNames listed above.

  • Central Nervous System Stimulant - [EPC] (Established Pharmacologic Class)
  • Methylxanthine - [EPC] (Established Pharmacologic Class)
  • Xanthines - [CS]
  • Central Nervous System Stimulation - [PE] (Physiologic Effect)
  • Central Nervous System Stimulant - [EPC] (Established Pharmacologic Class)
  • Methylxanthine - [EPC] (Established Pharmacologic Class)
  • Xanthines - [CS]
  • Central Nervous System Stimulation - [PE] (Physiologic Effect)

Product Labeler Information

What is the Labeler Name?
Name of Company corresponding to the labeler code segment of the Product NDC.

Labeler Name: Fresenius Kabi Usa, Llc
Labeler Code: 63323
FDA Application Number: ANDA077997 What is the FDA Application Number?
This corresponds to the NDA, ANDA, or BLA number reported by the labeler for products which have the corresponding Marketing Category designated. If the designated Marketing Category is OTC Monograph Final or OTC Monograph Not Final, then the Application number will be the CFR citation corresponding to the appropriate Monograph (e.g. “part 341”). For unapproved drugs, this field will be null.

Marketing Category: ANDA - A product marketed under an approved Abbreviated New Drug Application. What is the Marketing Category?
Product types are broken down into several potential Marketing Categories, such as NDA/ANDA/BLA, OTC Monograph, or Unapproved Drug. One and only one Marketing Category may be chosen for a product, not all marketing categories are available to all product types. Currently, only final marketed product categories are included. The complete list of codes and translations can be found at www.fda.gov/edrls under Structured Product Labeling Resources.

Start Marketing Date: 11-19-2009 What is the Start Marketing Date?
This is the date that the labeler indicates was the start of its marketing of the drug product.

Listing Expiration Date: 12-31-2021 What is the Listing Expiration Date?
This is the date when the listing record will expire if not updated or certified by the product labeler.

Exclude Flag: N - NO What is the NDC Exclude Flag?
This field indicates whether the product has been removed/excluded from the NDC Directory for failure to respond to FDA"s requests for correction to deficient or non-compliant submissions ("Y"), or because the listing certification is expired ("E"), or because the listing data was inactivated by FDA ("I"). Values = "Y", "N", "E", or "I".

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Caffeine Citrate Product Labeling Information

The product labeling information includes all published material associated to a drug. Product labeling documents include information like generic names, active ingredients, ingredient strength dosage, routes of administration, appearance, usage, warnings, inactive ingredients, etc.

Product Labeling Index

Other

Rx only

Manufactured by:Fresenius Kabi Lake Zurich, IL 60047 www.fresenius-kabi.us451408A Revised: March 2017

Description:

Caffeine citrate injection, USP for intravenous administration is a 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 sodium citrate dihydrate and Water for Injection. Caffeine, a central nervous system stimulant, is an odorless white crystalline powder or granule, with a bitter taste.  It is sparingly soluble in water and ethanol at room temperature.  The chemical name of caffeine is 3,7-dihydro-1,3,7-trimethyl-1H-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.

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 A1 and A2 subtypes, by caffeine, which has been demonstrated in receptor binding assays and observed at concentrations approximating those achieved therapeutically.

Pharmacokinetics

AbsorptionAfter oral administration of 10 mg caffeine base/kg to preterm neonates, the peak plasma level (Cmax) for caffeine ranged from 6 to 10 mg/L and the mean time to reach peak concentration (Tmax) ranged from 30 minutes to 2 hours.  The Tmax was not affected by formula feeding.  The absolute bioavailability, however, was not fully examined in preterm neonates.DistributionCaffeine 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%.MetabolismHepatic 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.EliminationIn young infants, the elimination of caffeine is much slower than that in adults due to immature hepatic and/or renal function.  Mean half-life (T1/2) and fraction excreted unchanged in urine (Ae) of caffeine in infants have been shown to be inversely related to gestational/postconceptual age.  In neonates, the T1/2 is approximately 3 to 4 days and the Ae is approximately 86% (within 6 days).  By 9 months of age, the metabolism of caffeine approximates that seen in adults (T1/2 = 5 hours and Ae = 1%).Special PopulationsStudies 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 evaluated1  45  37  % of patients with zero apnea events on day 2  26.7  8.1  0.03  Apnea rate on day 2 (per 24h)  4.9  7.2  0.134  % of patients with 50% reduction in apnea events from baseline on day 2  76  57  0.07 1Of 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.

Indications And Usage:

Caffeine citrate injection is indicated for the short-term treatment of apnea of prematurity in infants between 28 and < 33 weeks gestational age.

Contraindications:

Caffeine citrate is contraindicated in patients who have demonstrated hypersensitivity to any of its components.

Warnings:

During the double-blind, placebo-controlled clinical trial, six cases of necrotizing enterocolitis developed among the 85 infants studied (caffeine=46, placebo=39), with three cases resulting in death.  Five of the six patients with necrotizing enterocolitis were randomized to or had been exposed to caffeine citrate. Reports in the published literature have raised a question regarding the possible association between the use of methylxanthines and development of necrotizing enterocolitis, although a causal relationship between methylxanthine use and necrotizing enterocolitis has not been established.  Therefore, as with all preterm infants, patients being treated with caffeine citrate should be carefully monitored for the development of necrotizing enterocolitis.

General

Apnea of prematurity is a diagnosis of exclusion.  Other causes of apnea (e.g., central nervous system disorders, primary lung disease, anemia, sepsis, metabolic disturbances, cardiovascular abnormalities, or obstructive apnea) should be ruled out or properly treated prior to initiation of caffeine citrate.Caffeine is a central nervous system stimulant and in cases of caffeine overdose, seizures have been reported.  Caffeine citrate should be used with caution in infants with seizure disorders.The duration of treatment of apnea of prematurity in the placebo-controlled trial was limited to 10 to 12 days.  The safety and efficacy of caffeine citrate for longer periods of treatment have not been established.  Safety and efficacy of caffeine citrate for use in the prophylactic treatment of sudden infant death syndrome (SIDS) or prior to extubation in mechanically ventilated infants have also not been established.

Cardiovascular

Although no cases of cardiac toxicity were reported in the placebo-controlled trial, caffeine has been shown to increase heart rate, left ventricular output, and stroke volume in published studies.  Therefore, caffeine citrate should be used with caution in infants with cardiovascular disease.

Renal And Hepatic Systems

Caffeine citrate should be administered with caution in infants 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 (see CLINICAL  PHARMACOLOGY, Pharmacokinetics,  Elimination and Special Populations).

Laboratory Tests

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.In the placebo-controlled clinical trial, caffeine levels ranged from 8 to 40 mg/L.  A therapeutic plasma concentration range of caffeine could not be determined from the placebo-controlled clinical trial.  Serious toxicity has been reported in the literature when serum caffeine levels exceed 50 mg/L.  Serum concentrations of caffeine may need to be monitored periodically throughout treatment to avoid toxicity. In clinical studies reported in the literature, cases of hypoglycemia and hyperglycemia have been observed.  Therefore, serum glucose may need to be periodically monitored in infants receiving caffeine citrate.

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.

Carcinogenesis, Mutagenesis, Impairment Of Fertility

In a 2-year study in Sprague-Dawley rats, caffeine (as caffeine base) administered in drinking water was not carcinogenic in male rats at doses up to 102 mg/kg or in female rats at doses up to 170 mg/kg (approximately 2 and 4 times, respectively, the maximum recommended intravenous loading dose for infants on a mg/m2 basis).  In an 18-month study in C57BL/6 mice, no evidence of tumorigenicity was seen at dietary doses up to 55 mg/kg (less than the maximum recommended intravenous loading dose for infants on a mg/m2 basis).Caffeine (as caffeine base) increased the sister chromatid exchange (SCE) SCE/cell metaphase (exposure time dependent) in an in vivo mouse metaphase analysis.  Caffeine also potentiated the genotoxicity of known mutagens and enhanced the micronuclei formation (5-fold) in folate-deficient mice.  However, caffeine did not increase chromosomal aberrations in in vitro Chinese hamster ovary cell (CHO) and human lymphocyte assays and was not mutagenic in an in vitro CHO/hypoxanthine guanine phosphoribosyltransferase (HGPRT) gene mutation assay, except at cytotoxic concentrations.  In addition, caffeine was not clastogenic in an in vivo mouse micronucleus assay. Caffeine (as caffeine base) administered to male rats at 50 mg/kg/day subcutaneously (approximately equal to the maximum recommended intravenous loading dose for infants on a mg/m2 basis) for 4 days prior to mating with untreated females, caused decreased male reproductive performance in addition to causing embryotoxicity.  In addition, long-term exposure to high oral doses of caffeine (3 g over 7 weeks) was toxic to rat testes as manifested by spermatogenic cell degeneration.

Pregnancy:

Teratogenic Effects: Pregnancy Category  CConcern for the teratogenicity of caffeine is not relevant when administered to infants.  In studies performed in adult animals, caffeine (as caffeine base) administered to pregnant mice as sustained release pellets at 50 mg/kg (less than the maximum recommended intravenous loading dose for infants on a mg/m2 basis), during the period of organogenesis, caused a low incidence of cleft palate and exencephaly in the fetuses.  There are no adequate and well-controlled studies in pregnant women.

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 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 InjuryFeeding IntoleranceSepsis1 (2.2) 4 (8.7)                    2 (4.3)                    0 (0) 2 (5.1)0 (0) CARDIOVASCULAR SYSTEM Hemorrhage1 (2.2) 0 (0)  DIGESTIVE SYSTEM Necrotizing EnterocolitisGastritisGastrointestinal Hemorrhage2 (4.3) 1 (2.2)1 (2.2)1 (2.6) 0 (0)0 (0) HEMIC AND LYMPHATIC SYSTEM Disseminated Intravascular Coagulation1 (2.2) 0 (0)  METABOLIC AND NUTRITIVE DISORDERS AcidosisHealing Abnormal 1 (2.2) 1 (2.2) 0 (0) 0 (0) NERVOUS SYSTEM Cerebral Hemorrhage1 (2.2) 0 (0)  RESPIRATORY SYSTEM DyspneaLung Edema1 (2.2) 1 (2.2)0 (0) 0 (0) SKIN AND APPENDAGES Dry SkinRashSkin Breakdown1 (2.2) 4 (8.7)1 (2.2)0 (0) 3 (7.7)0 (0) SPECIAL SENSES Retinopathy of Prematurity1 (2.2) 0 (0)  UROGENITAL SYSTEM Kidney Failure1 (2.2) 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.

Overdosage:

Following overdose, serum caffeine levels have ranged from approximately 24 mg/L (a post marketing spontaneous case report in which an infant exhibited irritability, poor feeding and insomnia) to 350 mg/L.  Serious toxicity has been associated with serum levels greater than 50 mg/L (see PRECAUTIONS,  Laboratory Tests and DOSAGE AND ADMINISTRATION).  Signs and symptoms reported in the literature after caffeine overdose in preterm infants include fever, tachypnea, jitteriness, insomnia, fine tremor of the extremities, hypertonia, opisthotonos, tonic-clonic movements, nonpurposeful jaw and lip movements, vomiting, hyperglycemia, elevated blood urea nitrogen, and elevated total leukocyte concentration.  Seizures have also been reported in cases of overdose.  One case of caffeine overdose complicated by development of intraventricular hemorrhage and long-term neurological sequelae has been reported.  Another case of caffeine citrate overdose (from New Zealand) of an estimated 600 mg caffeine citrate (approximately 322 mg/kg) administered over 40 minutes was complicated by tachycardia, ST depression, respiratory distress, heart failure, gastric distention, acidosis and a severe extravasation burn with tissue necrosis at the peripheral intravenous injection site.  No deaths associated with caffeine overdose have been reported in preterm infants. Treatment of caffeine overdose is primarily symptomatic and supportive.  Caffeine levels have been shown to decrease after exchange transfusions.  Convulsions may be treated with intravenous administration of diazepam or a barbiturate such as pentobarbital sodium.

Dosage And Administration:

Prior to initiation of caffeine citrate injection, 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/kgRoute   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 doseNOTE 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 injection 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, 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 HCI 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 1,000 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%

How Supplied:

Caffeine citrate injection, USP is available as a clear, colorless, sterile, non-pyrogenic, preservative-free, aqueous solution in colorless glass vials. The vials contain 3 mL of 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 Product No. NDC  No. Strength  Vial size  PRX400703   63323-407-04    60 mg per 3 mL   (20 mg per mL) 3 mL fill, in a 6 mL single dose vial, packaged individually. STORE AT: 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature].Preservative free.  For single use only.  Discard unused portion.The container closure is not made with natural rubber latex.The brand names mentioned in this document are the trademarks of their respective owners.PREMIERProRx® is a registered trademark of Premier Healthcare Alliance, L.P., used under license.

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