Peyona Dosage/Direction for Use

Treatment with caffeine citrate should be initiated under the supervision of a physician experienced in neonatal intensive care. Treatment should be administered only in a neonatal intensive care unit in which adequate facilities are available for patient surveillance and monitoring.
Posology: The recommended dose regimen in previously untreated infants is a loading dose of 20 mg caffeine citrate per kg body weight administered by slow intravenous infusion over 30 minutes, using a syringe infusion pump or other metered infusion device. After an interval of 24 hours, maintenance doses of 5 mg per kg body weight may be administered by slow intravenous infusion over 10 minutes every 24 hours. Alternatively, maintenance doses of 5 mg per kg body weight may be administered by oral administration, such as through a nasogastric tube every 24 hours.
The recommended loading dose and maintenance doses of caffeine citrate are provided in the following table which clarifies the relationship between injection volumes and administered doses expressed as caffeine citrate.
The dose expressed as caffeine base is one - half the dose when expressed as caffeine citrate (20 mg caffeine citrate are equivalent to 10 mg caffeine base). (See Table 2.)

Click on icon to see table/diagram/image

In preterm newborn infants with insufficient clinical response to the recommended loading dose, a second loading dose of 10-20 mg/kg maximum may be given after 24 hours.
Higher maintenance doses of 10 mg/kg body weight could be considered in case of insufficient response, taking into account the potential for accumulation of caffeine due to the long half-life in preterm newborn infants and the progressively increasing capacity to metabolise caffeine in relation to post-menstrual age (see Pharmacology: Pharmacokinetics under Actions). Where clinically indicated, caffeine plasma levels should be monitored. The diagnosis of apnoea of prematurity may need to be reconsidered if patients do not respond adequately to a second loading dose or maintenance dose of 10 mg/kg/day (see Precautions).
Dosage adjustments and monitoring: Plasma concentrations of caffeine may need to be monitored periodically throughout treatment in cases of incomplete clinical response or signs of toxicity.
Additionally, doses may need to be adjusted according to medical judgment following routine monitoring of caffeine plasma concentrations in at risk situations such as: very premature infants (< 28 weeks gestational age and/or body weight < 1000 g) particularly when receiving parenteral nutrition, infants with hepatic and renal impairment (see Precautions and Pharmacology: Pharmacokinetics under Actions), infants with seizure disorders, infants with known and clinically significant cardiac disease, infants receiving co-administration of medicinal products known to interfere with caffeine metabolism (see Interactions), infants whose mothers consume caffeine while providing breast milk for feeding.
It is advisable to measure baseline caffeine levels in: infants whose mothers may have ingested large quantities of caffeine prior to delivery (see Precautions), infants who have previously been treated with theophylline, which is metabolized to caffeine.
Caffeine has a prolonged half-life in premature newborn infants and there is potential for accumulation which may necessitate monitoring infants treated for an extended period (see Pharmacology: Pharmacokinetics under Actions).
Blood samples for monitoring should be taken just before the next dose in the case of therapeutic failure and 2 to 4 hours after the previous dose when suspecting toxicity.
Although a therapeutic plasma concentration range of caffeine has not been determined in the literature, caffeine levels in studies associated with clinical benefit ranged from 8 to 30 mg/l and no safety concerns have normally been raised with plasma levels below 50 mg/l.
Duration of treatment: The optimal duration of treatment has not been established. In a recent large multicentre study on preterm newborn infants a median treatment period of 37 days was reported.
In clinical practice, treatment is usually continued until the infant has reached a post-menstrual age of 37 weeks, by which time apnoea of prematurity usually resolves spontaneously. This limit may however be revised according to clinical judgment in individual cases depending on the response to treatment, the continuing presence of apnoeic episodes despite treatment, or other clinical considerations. It is recommended that caffeine citrate administration should be stopped when the patient has 5-7 days without a significant apnoeic attack.
If the patient has recurrent apnoea, caffeine citrate administration can be restarted with either a maintenance dose or a half loading dose, depending upon the time interval from stopping caffeine citrate to recurrence of apnoea.
Because of the slow elimination of caffeine in this patient population, there is no requirement for dose tapering on cessation of treatment.
As there is a risk for recurrence of apnoeas after cessation of caffeine citrate treatment monitoring of the patient should be continued for approximately one week.
Hepatic and renal impairment: There is limited experience in patients with renal and hepatic impairment. In a post authorisation safety study, the frequency of adverse reactions in a small number of very premature infants with renal/hepatic impairment appeared to be higher as compared to premature infants without organ impairment (see Precautions and Adverse Reactions).
In the presence of renal impairment, there is increased potential for accumulation. A reduced daily maintenance dose of caffeine citrate is required and the dose should be guided by plasma caffeine measurements.
In very premature infants, clearance of caffeine does not depend on hepatic function. Hepatic caffeine metabolism develops progressively in the weeks following birth and for the older infants, hepatic disease may indicate a need for monitoring caffeine plasma levels and may require dose adjustments (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Method of administration: Caffeine citrate can be administered by intravenous infusion and by the oral route. The medicinal product must not be administered by intramuscular, subcutaneous, intrathecal or intraperitoneal injection.
When given intravenously, caffeine citrate should be administered by controlled intravenous infusion, using a syringe infusion pump or other metered infusion device only. Caffeine citrate can be either used without dilution or diluted in sterile solutions for infusion such as glucose 50 mg/ml (5%); or sodium chloride 9 mg/ml (0.9%) or calcium gluconate 100 mg/ml (10%) immediately after withdrawal from the ampoule (see Special precautions for disposal and other handling under Cautions for Usage).