Caffeine citrate for very preterm infants: Effects on development, temperament and behaviour.

AIM: To compare two dosing regimens for caffeine citrate for neonates born less than 30 weeks gestation in terms of development, temperament and behaviour. METHODS: A multi-centre, randomised, controlled trial design was undertaken. A total of 287 infants with apnoea of prematurity or in the peri-extubation period were randomised to receive one of two dosage regimens (20 vs. 5 mg/kg/day). The main outcome measure was cognitive development at 1 year of age on the Griffiths Mental Development Scales. Secondary outcome measures included neonatal morbidity, death and disability, temperament at 1 year and behaviour at 2 years of age. RESULTS: Data on the primary outcome were available for 190 survivors at 12 months corrected for prematurity. A significantly greater mean general quotient was found in the high-dose group (mean (standard deviation), 98.0 (13.8) vs. 93.6 (16.5), P = 0.048). On omission of two infants for whom cognitive assessment was not possible because of disability while the mean general quotient remained higher for infants in the high-dose group, this was no longer statistically significant (P= 0.075). There was a non-significant trend for benefit in the high-dose caffeine group for death or major disability, 15.4% versus 24.2%; relative risk 0.75 (95% confidence interval 0.49-1.14). No differences in the mean values between the two groups were shown for temperament and behaviour. CONCLUSIONS: Caffeine citrate with a dosage regimen of 20 mg/kg/day did not result in adverse outcomes for development, temperament and behaviour. The borderline benefit in cognition with high-dose caffeine needs further investigation.

Caffeine versus theophylline for apnea in preterm infants.

BACKGROUND: Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia, which may be severe enough to require resuscitation including use of positive pressure ventilation. Two forms of methylxanthine (caffeine and theophylline) have been used to stimulate breathing in order to prevent apnea and its consequences. OBJECTIVES: To evaluate the effect of caffeine compared with theophylline treatment on the risk of apnea and use of mechanical ventilation in preterm infants with recurrent apnea. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases in August 2009: Oxford Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2009); MEDLINE (1966 to April 2009); and EMBASE Drugs and Pharmacology (1990 to April 2009), previous reviews including cross references. SELECTION CRITERIA: Randomized and quasi-randomized trials comparing caffeine to theophylline for treating apnea in preterm infants and reporting effects on apnea event rates. DATA COLLECTION AND ANALYSIS: Each author assessed eligibility and trial quality, extracted data separately and compared and resolved differences. Study authors were contacted for additional information. MAIN RESULTS: Five trials involving a total of 108 infants were included. The quality of most of these small trials was fair to good. No difference in treatment failure rate (less than 50% reduction in apnea/bradycardia) was found between caffeine and theophylline after one to three days treatment (based on two studies) or five to seven days treatment (based on one study). There was no difference in mean apnea rate between caffeine and theophylline groups after one to three days treatment (based on five trials) and five to seven days treatment (based on four trials).Adverse effects, indicated by tachycardia or feed intolerance leading to change in dosing, were lower in the caffeine group (summary relative risk 0.17, 95% CI 0.04 to 0.72). This was reported and consistent in three studies.No trial reported the use of ventilation and no data were available to assess effects on growth and development. AUTHORS' CONCLUSIONS: Caffeine appears to have similar short-term effects on apnea/bradycardia as does theophylline although caffeine has certain therapeutic advantages over theophylline. Theophylline is associated with higher rates of toxicity. The possibility that higher doses of caffeine might be more effective in extremely preterm infants needs further evaluation in randomized clinical trials.

Caffeine citrate treatment for extremely premature infants with apnea: population pharmacokinetics, absolute bioavailability, and implications for therapeutic drug monitoring.

The objective of this study was to develop a population model of the pharmacokinetics (PK) of caffeine after orogastric or intravenous administration to extremely premature neonates with apnea of prematurity who were to undergo extubation from ventilation. Infants of gestational age <30 weeks were randomly allocated to receive maintenance caffeine citrate dosing of either 5 or 20 mg/kg/d. Four blood samples were drawn at prerandomized times from each infant during caffeine treatment. Serum caffeine was assayed by enzyme-multiplied immunoassay technique. Concentration data (431 samples, median: 4 per subject) were obtained from 110 (52 male) infants of mean birth weight of 1009 g, current mean weight (WT) of 992 g, mean gestational age of 27.6 weeks, and mean postnatal age (PNA) of 12 days. Of 1022 doses given, 145 were orogastric, permitting estimation of absolute bioavailability. A 1-compartment model with first-order absorption was fitted to the data in NONMEM. Patient characteristics were screened (P < 0.01) in nested models for pharmacokinetic influence. Model stability was assessed by nonparametric bootstrapping. Clearance (CL) increased nonlinearly with increasing PNA, whereas volume of distribution (Vd) increased linearly with WT, according to the following allometric models: CL (L/h) = 0.167 (WT/70) (PNA/12); Vd (L) = 58.7 (WT/70). The mean elimination half-life was 101. Interindividual variability (IIV) of CL and Vd was 18.8 % and 22.3 %, respectively. Interoccasion variability (IOV) of CL and Vd was 35.1% and 11.1%, respectively. This study established that the elimination of caffeine was severely depressed in extremely premature infants but increased nonlinearly after birth up to age 6 weeks. Caffeine was completely absorbed, which has favorable implications for switching between intravenous and orogastric routes. The interoccasion variability about CL was twice the interindividual variability, which, among other factors, indicates that routine serum concentration monitoring of caffeine in these patients is not warranted.

Vitamin C, diclophenac, and L-arginine protect endothelium-dependent vasodilation against elevated circulating fatty acid levels in humans.

An acute elevation of circulating non-esterified fatty acids (NEFAs) has previously been shown to impair endothelium-dependent vasodilation (EDV). In this study, we investigated if local administration of vitamin C (n=8, 18 mg/min), L-arginine (n=8, 12.5 mg/min), or the cyclooxygenase (COX) inhibitor diclophenac (n=8, 0.5 mg/min) can counteract the endothelial dysfunction seen during infusion of Intralipid plus heparin (n=10). EDV and endothelium-independent vasodilation (EIDV) were studied in the forearm after local administration of methacholine chloride (Mch; 2 and 4 microg/min) and sodium nitroprusside (SNP; 5 and 10 microg/min). Forearm blood flow (FBF) was determined with venous occlusion plethysmography. Intralipid and heparin increased circulating NEFA levels sevenfold and impaired EDV (P<0.001 vs baseline). Concomitant administration of L-arginine or diclophenac abolished the NEFA-induced impairment in EDV. Concomitant vitamin C administration actually improved EDV (P<0.05 vs baseline). NEFA elevation increased EIDV (P<0.01), but this effect was not significant after L-arginine or diclophenac infusions. In conclusion, an acute elevation of circulating NEFAs led to impaired EDV. Administration of L-arginine, vitamin C or COX inhibition abolished this effect, suggesting that NEFAs might interact with endothelial vasodilatory function through multiple mechanisms.

Acute elevations of medium- and long-chain fatty acid have different impacts on endothelium-dependent vasodilation in humans.

It has previously been shown that acute elevation of long-chain fatty acids (LCFA) impairs endothelium-dependent vasodilation (EDV) in humans. In this study, we tested the hypothesis that an elevation of both medium-chain fatty acids (MCFA) and LCFA affects the endothelium differently from LCFA elevation alone. Ten healthy volunteers received an intravenous infusion of Structolipid (structured TG, MCFA/LCFA ratio 1:1) and heparin for 2 h, while another 10 subjects received an infusion of Intralipid (LCFA only) and heparin. EDV and endothelium-independent vasodilation (EIDV) were studied in the forearm after local administration of methacholine chloride (2 and 4 microg/min) and sodium nitroprusside (5 and 10 microg/min). Forearm blood flow was determined by venous occlusion plethysmography. Intralipid and heparin increased circulating FA levels from 0.2 +/- 0.1 to 1.4 +/- 0.5 mmol/L (P < 0.001) and reduced EDV by 20% (P < 0.01). Although Structolipid and heparin increased circulating FA levels to a similar extent (from 0.4 +/- 0.1 to 1.8 +/- 0.4 mmol/L after 2 h), EDV was not significantly changed. EIDV increased slightly during both interventions (P < 0.05). In conclusion, an acute elevation of LCFA attenuated EDV, whereas an elevation of both MCFA and LCFA did not influence EDV. Thus, FA composition seems to be of importance for EDV in healthy humans.

The effect of a mixed meal on endothelium-dependent vasodilation is dependent on fat content in healthy humans.

Impaired endothelium-dependent vasodilation (EDV) is an early marker of atherosclerosis. The aim of the present study was to investigate how meals with different fat contents influence endothelial vasodilatory function. A total of 26 young, healthy men and women aged 20-30 years ingested an ordinary Western meal [34 energy% (E%) fat, n =10], or isocaloric meals with low-fat (20 E%, n =8), or minimal-fat (3 E%, n =8) content. EDV was assessed as forearm blood flow (FBF) during local administration of 4 microg/min methacholine chloride (Mch-FBF) and endothelium-independent vasodilation as FBF during administration of 10 microg/min sodium nitroprusside (SNP-FBF) at baseline and 1 and 2 h after each meal. FBF was determined by venous occlusion plethysmography. An endothelial function index (EFI) was calculated as the Mch-FBF/SNP-FBF ratio. Both Mch-FBF and the EFI were decreased at 1 h after the 34 E% fat meal ( P <0.01 and P <0.05 respectively), but approached fasting levels after 2 h. Mch-FBF and EFI did not change significantly in the group consuming the 20 E% fat meal, but increased in the 3 E% fat group ( P <0.01 and P <0.05 compared with baseline for Mch-FBF and EFI respectively). SNP-FBF was not significantly affected by any of the meals. In conclusion, low-fat meals did not attenuate EDV, in contrast with an ordinary Western meal, which transiently impaired EDV. Our findings indicate that a dietary fat content of 20 E% or less might be beneficial to endothelial vasodilatory function.

Cardiac and vascular structure and function are related to lipid peroxidation and metabolism.

The present study investigated possible relationships between left ventricular mass, intima-media thickness of the carotid artery (IMT), total arterial compliance, and lipid status in a population sample of 58 apparently healthy subjects aged 20 to 69. By stepwise multiple regression analysis, including age, blood pressure, and smoking, left ventricular mass index, measured by M-mode echocardiography, increased by 13.0 g/m2 for each 1 standard deviation (SD = 0.11 microM, r = 0.60, P< 0.01) increase in plasma malondialdehyde and 9.50 g/m2 per SD increase in plasma 8-iso-prostaglandin F2alpha in women only (SD = 8.88 ng/L, r = 0.44, P = 0.01). Each 1-SD (SD = 0.27 g/L) increase in apolipoprotein B was associated with a 63 microm increase in IMT (r = 0.47, P = 0.014) and a 0.27 mL/min/m2/mm Hg (r = -0.60, P < 0.01) decrease in stroke index/pulse pressure ratio, reflecting total arterial compliance in women. In men, each 1-SD increase in the proportion of stearic acid (18:0) in serum cholesterol esters (SD = 0.12 percent units) reduced the transmitral E/A ratio, measured by Doppler echocardiography, reflecting left ventricular diastolic function, by 0.10 units (r = -0.29, P < 0.05). Thus, important cardiovascular characteristics, such as left ventricular mass, left ventricular diastolic function, carotid IMT, and total arterial compliance, were independently predicted by indices of lipid metabolism and peroxidation in apparently healthy subjects.

Endothelial vasodilatory function is predicted by circulating apolipoprotein B and HDL in healthy humans.

Endothelium-dependent vasodilation (EDV), LDL particle size, and antibodies against oxidized LDL (oxLDLab) have been shown to be related to the development of atherosclerosis and cardiovascular disease. In this study, we investigated whether LDL particle size, oxLDLab, apolipoproteins, and lipoproteins are related to endothelial vasodilatory function in a population sample of 58 apparently healthy subjects aged 20 to 69 yr. EDV and endothelium-independent vasodilation (EIDV) were studied in the forearm during local administration of methacholine chloride (2 and 4 microg/min) or sodium nitroprusside (5 and 10 microg/min). Forearm blood flow was determined with venous occlusion plethysmography. In multiple stepwise regression analyses, neither oxLDLab nor small LDL particles were significantly predictive of endothelial vasodilatory function. Instead, a high level of apolipoprotein B (apoB) was an independent predictor of both attenuated EDV and EIDV (r = -0.43, P < 0.01, and r = -0.34, P < 0.05, respectively). HDL cholesterol, on the other hand, was the only lipid variable that was significantly related to the EDV to EIDV ratio, an index of endothelial vasodilatory function (r = 0.35, P < 0.01). The inverse associations between apoB and both EDV and EIDV indicate that apoB might be an early marker of structural vascular changes in healthy subjects, whereas HDL seems to be more specifically related to endothelial vasodilatory function.