CAFFEINE

Other Names:
1,3,7-trimethylxanthine, Anhydrous Caffeine, Caffeine and Sodium Benzoate, Caffeine
Anhydrous, Caffeine Citrate, Citrated Caffeine, Methylxanthine, Trimethylxanthine

INTRODUCTION

Caffeine is the most widely consumed behaviour-modifying drug in the world. It occurs naturally
in about 60 species of plants, most commonly in coffee beans, tea leaves, cocoa seeds and the
cola nut (Thomas, 1990; Greener, 1993).

Social consumption of coffee, tea and cola or energy-boosting soft drinks is the most common
source of caffeine, although decaffeinated versions of these drinks are becoming increasingly
popular in the developed world.

Caffeine is also found in a range of over-the-counter analgesic medications, which must be

included when calculating a patient's daily caffeine consumption.

Caffeine is most commonly used to improve mental alertness, but it has many other uses.
Caffeine is used by mouth or rectally in combination with painkillers (such as aspirin and
acetaminophen) and a chemical called ergotamine for treating migraine headaches. It is also
used with painkillers for simple headaches and preventing and treating headaches after epidural
anesthesia.

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CLASSIFICATION

Caffeine is classified as a stimulant. Caffeine works by stimulating the central nervous system
(CNS), heart, muscles, and the centers that control blood pressure. Caffeine can raise blood
pressure, but might not have this effect in people who use it all the time. Coffee stimulates
colonic motor and bowel activity (Brown et a1, 1990; Addison, 1999).Caffeine can also act like a
“water pill” or a diuretic that increases urine flow. But again, it may not have this effect in people
who use caffeine regularly. Caffeine has a diuretic effect, which increases urine output (Leonard
et al, 1987) and could contribute to dehydration. Creighton and Stanton (1990) found that it
increases urgency and frequency in patients with proven detrusor instability. Urethral pressure
may be reduced by caffeine, which could also increase the risk of stress incontinence.
SIDE EFFECTS/ ADVERSE EFFECTS

Caffeine is LIKELY SAFE for most adults when used appropriately. Caffeine can cause
insomnia, nervousness and restlessness, stomach irritation, nausea and vomiting, increased
heart rate and respiration, and other side effects. Caffeine can make sleep disorders in patients
with acquired immunodeficiency syndrome (AIDS) worse. Larger doses might cause headache,
anxiety, agitation, chest pain, and ringing in the ears.

Large doses may be UNSAFE and can cause irregular heartbeats and even death.

Anxiety disorders: Caffeine might make these conditions worse. Use with care.

Bipolar disorder: Too much caffeine might make this condition worse. In one case, a 36-year-
old man with controlled bipolar disorder was hospitalized with symptoms of mania after drinking
several cans of an energy drink containing caffeine, taurine, inositol, and other ingredients (Red
Bull Energy Drink) over a period of 4 days. Use caffeine with care and in low amounts if you
have bipolar disorder.

Bleeding disorders: There is concern that caffeine might aggravate bleeding disorders. Use
caffeine with care if you have a bleeding disorder.

Heart conditions: Caffeine can cause irregular heartbeat in sensitive people. Use caffeine with
caution.

Diabetes: Some research suggests that caffeine may affect the way the body uses sugar and
might worsen diabetes. But the effect of caffeinated beverages and herbs has not been studied.
If you have diabetes, use caffeine with caution.

Glaucoma: Caffeine increases the pressure inside the eye. The increase occurs within 30
minutes and lasts for at least 90 minutes after drinking caffeinated beverages.

High blood pressure: Consuming caffeine might increase blood pressure in people with high
blood pressure. However, this effect might be less in people who use caffeine regularly.

Weak bones (osteoporosis): Caffeine can increase the amount of calcium that is flushed out in
the urine. If you have osteoporosis or low bone density, caffeine should be limited to less than
300 mg per day (approximately 2-3 cups of coffee). It’s also a good idea to get extra calcium to
make up for the amount that may be lost in the urine. Older women with an inherited disorder
that affects the way vitamin D is used should use caffeine with caution. Vitamin D works with
calcium to build bones.
WITHDRAWAL SYMPTOMS

The most frequent symptom associated with caffeine withdrawal is moderate to severe
headache. This can occur between 12 and 24 hours after last intake of caffeine. It usually lasts
for one to two days, though some may have a headache for longer. If you are purposefully
attempting to stop consuming caffeine, be certain to check labels on pain medications. Some
medications combine caffeine with acetaminophen and aspirin, since caffeine is an effective
pain reliever.

Others experiencing caffeine withdrawal may feel depressed and some feel sleepy. These
include headaches, drowsiness, stomach upsets, irritability, depression, nausea, nervousness,
muscle pains, sweating, a runny nose, feelings of fullness in the head and tremor (Thomas,
1990; Greener, 1993). Some people may experience significant mood instability, which may be
helped by prescribed medications. People may also have difficulty concentrating. Some
undergoing caffeine withdrawal can have flu-like symptoms that include nausea or vomiting, and
muscle pain or stiffness.

Generally the symptoms of caffeine withdrawal continue from two to nine days after one’s last
intake of caffeine. People may note continued symptoms of sleepiness that may be more
psychologically based, if they used caffeine to start their morning. However, the body is
considered no longer addicted to caffeine after nine days. Continued symptoms should be
checked by a doctor, as they might indicate other conditions.

Most people will not feel the effects of caffeine withdrawal three to four days after stopping
caffeine. So though caffeine is addictive, it is actually generally a far easier substance to break
addiction from. This is good news for those people who must stop using caffeine as per a
doctor’s recommendations.

People may miss the taste of some caffeinated beverages, particularly coffee. One can drink
decaffeinated coffee, which contains a tiny amount of caffeine, if a doctor okays this beverage.
For people who enjoy caffeine rich soda, there are now many caffeine free sodas available.

NURSING IMPLICATIONS

Ephedrine interacts with CAFFEINE-Stimulant drugs speed up the nervous system. Caffeine
and ephedrine are both stimulant drugs. Taking caffeine along with ephedrine might cause too
much stimulation and sometimes serious side effects and heart problems. Do not take
caffeine-containing products and ephedrine at the same time.

In patients with slow-gut-transit constipation, coffee could maintain or improve bowel function
(Rao et al, 1998). But for patients with diarrhoea or faecal continence problems, the best advice
may be to stop drinking it (Rao et al, 1998).

Nurses must also bear in mind that decaffeinated coffee can have the same effect on bowel
function as caffeinated coffee.

Patients who are involved in any form of gut motility study should have their intake of caffeine
and other drugs checked, including over-the-counter medications, as these may have a bearing
on the results.
Although most people become tolerant of the effects of caffeine and are not addicted to it,
Thomas (1990) suggests a maximum daily intake of about six cups/four mugs of coffee.

Giving up or restricting caffeine intake is recommended during pregnancy and women should
restrict themselves to one cup of coffee a day when breastfeeding (Greener, 1993). A low intake
of caffeine is also recommended for people with hypertension, kidney disease, high cholesterol
levels or heart disease (Leonard et al, 1987; Thomas, 1990).

If decaffeinated drinks are used, ensure that the caffeine has not been extracted using a
chemical method (Thomas, 1990). Chemical extraction has been associated with health risks
and it is advisable to select a brand that uses water or carbon dioxide to extract the caffeine.

Nurses should also be aware that patients, particularly those who are prone to food allergies,
can develop allergies to coffee and tea (Leonard et al, 1987).

INDICATIONS

• Headache, including migraine and headache following surgery. Caffeine is an FDA-

approved product for use with painkilling medications for improving pain relief.

• Mental alertness. Drinking caffeinated beverages throughout the day keeps the mind
alert according to most research. Combining caffeine with glucose as an “energy drink”
seems to improve mental performance better than either caffeine or glucose alone.

• Improving athletic performance. Caffeine seems to increase physical endurance and

may delay exhaustion. But caffeine doesn't seem to help short-term, high-intensity exercise
such as sprinting and lifting.
• Preventing dizziness on standing up (orthostatic hypotension) in older people.
Dizziness on standing is sometimes a result of low blood pressure. Drinking caffeinated
beverages seems to increase blood pressure in older people with low blood pressure.
• Preventing Parkinson’s disease. There is some evidence that suggests people who
drink caffeinated beverages such as coffee, tea, and cola have a decreased risk of
Parkinson’s disease.
• Asthma. Caffeine appears to improve airway function somewhat in people with asthma
for up to four hours.
• Preventing type 2 diabetes, when caffeine is acquired from drinking coffee or tea.
Drinking coffee or tea is associated with a lower risk of developing type 2 diabetes. It appears
that the more the caffeine, the lower the risk. In North American men, consuming 417 mg of
caffeine per day from coffee or tea is associated with 20% lower risk of developing type 2
diabetes compared to men who consume less than 37 mg per day. North American women
consuming 258 mg to 530 mg of caffeine per day from coffee or tea seem to have 10% to 30%
lower risk of developing type 2 diabetes compared to women consuming less than 140 mg per
day. Similarly, Japanese adults who consume 416 mg or more of caffeine per day from
beverages including coffee or green tea seem to have a 33% lower risk of developing type 2
diabetes compared to those who consume 57 mg/day or less.
 • Breathing problems in infants. Caffeine given by mouth or intravenously (by IV)
appears to improve breathing in infants born too early. It seems to reduce the number of
episodes of shortness of breath by at least 50% over 7-10 days of treatment.
• Preventing gallstones. Drinking caffeinated beverages that provide 400 mg or more of
caffeine per day seems to significantly reduce the risk of developing gallstone disease. The
effect seems to be dose-dependent. Taking 800 mg caffeine per day seems to work best.
• Weight loss, when given with other drugs. Taking caffeine in combination with
ephedrine seems to help reduce weight short-term. Taking 192 mg of caffeine in combination
with 90 mg of ephedra per day for 6 months seems to cause a modest weight reduction (5.3
kg or 11.66 pounds) in overweight people (people with a body mass index (BMI) between 25-
40). This combination, along with limiting fat intake to 30 percent of calories and moderate
exercise, also seems to reduce body fat, decrease “bad” low-density lipoprotein (LDL)
cholesterol, and increase “good” high-density lipoprotein (HDL) cholesterol. But there can be
unwanted side effects. Even in carefully screened and monitored otherwise healthy adults,
caffeine/ephedra combinations can cause changes in blood pressure and heart rate.
• Headache after epidural anesthesia.

SPECIAL CONSIDERATIONS

Some people need to take special care with caffeine:

• Pregnant women – limit caffeine intake to 200mg per day or less, or avoid it altogether.
Consuming high amounts of caffeine may increase your risk of miscarriage, experiencing a
difficult birth and having a baby with a low birthweight.
• Breastfeeding- Caffeine passes into breast milk, so nursing mothers should closely monitor
caffeine intake to make sure it is on the low side. Caffeine in large amounts is POSSIBLY
UNSAFE during breast-feeding. Caffeine can cause sleep disturbances, irritability, and
increased bowel activity in breast-fed infants.
• Athletes – caffeine is not classified as a prohibited substance under the World Anti-Doping
Code 2005 Prohibited List. However, athletes should check the anti-doping rules of particular
sports to ensure caffeine is not specified as a restricted drug for that sport.
• Children – at present there are no guidelines for children’s intake of caffeine. Caffeine intake
should be investigated if children are showing symptoms of irritability, inability to sleep,
interrupted sleep or stomach upsets. Remember that caffeine is present in many soft drinks and
chocolate, not just coffee and tea.

UPDATE
F. D.A. Says It May Ban Alcoholic Drinks With Caffeine
By GARDINER HARRIS
Published: November 13, 2009

WASHINGTON — Top federal food regulators threatened on Friday to ban caffeinated alcoholic
drinks unless their makers quickly proved that the beverages were safe.
In a statement, the Food and Drug Administration said it had told nearly 30 manufacturers of
the drinks that unless they could provide clear evidence of safety, it would “take appropriate
action to ensure that the products are removed from the marketplace.” Officials did not say how
long such a determination might take.
The drinks, which combine malt liquor or other spirits with caffeine and fruit juices at alcohol
concentrations up to about 10 percent, have become increasingly popular among college
students. In a news conference, Dr. Joshua M. Sharfstein, the agency’s principal deputy
commissioner, said their consumption was associated with increased risk of serious injury,
drunken driving, sexual assault and other dangerous behavior.
The agency’s action was prompted by a letter from 19 state attorneys general, who expressed
concern about the products’ safety.
Caffeine may lead people to underestimate how drunk they are, giving drinkers a false sense of
confidence that they can perform tasks they are too impaired to undertake.
After pressure from the attorneys general, Anheuser-Busch last year eliminated caffeine and
other additives from its flavored malt beverages, Tilt and Bud Extra. And MillerCoors agreed to
stop selling its product Sparks.
The brands under scrutiny, which include Joose from United Brands, are being marketed to
young people with social marketing tools. United Brands, for instance, has a Twitter site to
market Joose.
A call to United Brands was not immediately returned.
Federal law requires makers of products that combine common ingredients to prove that the
combinations are safe.
“F.D.A. is not aware of any basis that manufacturers have to conclude that the use of caffeine
added to alcoholic beverages is generally recognized as safe,” Dr. Sharfstein said.
The Center for Science in the Public Interest, an advocacy group whose lawsuit against
MillerCoors over its marketing of Sparks preceded the company’s decision to stop selling the
product, praised the agency’s action.
“For many years,” the group said in a statement, “federal regulators have stood mutely by as
these potentially dangerous products, which resemble nonalcoholic energy drinks in many
ways, gained in popularity among young people.
“In fact, emerging research suggests that the young consumers of these products are more
likely to be the perpetrator or victim of sexual aggression, to ride with an intoxicated driver or to
become otherwise injured.”
Attorney General Richard Blumenthal of Connecticut, who co-wrote the letter to the F.D.A., said
he was pleased. “Our battle against alcoholic energy drinks has stopped some products,” Mr.
Blumenthal said, “but others are insidiously exploiting the void.”