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Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class.[9] It is mainly used as a eugeroic (wakefulness promoter) or as a mild cognitive enhancer to increase alertness and attentional performance.[10][11] Caffeine acts by blocking binding of adenosine to the adenosine A1 receptor, which enhances release of the neurotransmitter acetylcholine.[12] Caffeine has a three-dimensional structure similar to that of adenosine, which allows it to bind and block its receptors.[13] Caffeine also increases cyclic AMP levels through nonselective inhibition of phosphodiesterase.[14]
Caffeine is a bitter, white crystalline purine, a methylxanthine alkaloid, and is chemically related to the adenine and guanine bases of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). It is found in the seeds, fruits, nuts, or leaves of a number of plants native to Africa, East Asia and South America,[15] and helps to protect them against herbivores and from competition by preventing the germination of nearby seeds,[16] as well as encouraging consumption by select animals such as honey bees.[17] The best-known source of caffeine is the coffee bean, the seed of the Coffea plant. People may drink beverages containing caffeine to relieve or prevent drowsiness and to improve cognitive performance. To make these drinks, caffeine is extracted by steeping the plant product in water, a process called infusion. Caffeine-containing drinks, such as coffee, tea, and cola, are consumed globally in high volumes. In 2020, almost 10 million tonnes of coffee beans were consumed globally.[18] Caffeine is the world's most widely consumed psychoactive drug.[19][20] Unlike most other psychoactive substances, caffeine remains largely unregulated and legal in nearly all parts of the world. Caffeine is also an outlier as its use is seen as socially acceptable in most cultures and even encouraged in others.
Caffeine has both positive and negative health effects. It can treat and prevent the premature infant breathing disorders bronchopulmonary dysplasia of prematurity and apnea of prematurity. Caffeine citrate is on the WHO Model List of Essential Medicines.[21] It may confer a modest protective effect against some diseases,[22] including Parkinson's disease.[23] Some people experience sleep disruption or anxiety if they consume caffeine,[24] but others show little disturbance. Evidence of a risk during pregnancy is equivocal; some authorities recommend that pregnant women limit caffeine to the equivalent of two cups of coffee per day or less.[25][26] Caffeine can produce a mild form of drug dependence – associated with withdrawal symptoms such as sleepiness, headache, and irritability – when an individual stops using caffeine after repeated daily intake.[27][28][2] Tolerance to the autonomic effects of increased blood pressure and heart rate, and increased urine output, develops with chronic use (i.e., these symptoms become less pronounced or do not occur following consistent use).[29]
Caffeine is classified by the US Food and Drug Administration as generally recognized as safe. Toxic doses, over 10 grams per day for an adult, are much higher than the typical dose of under 500 milligrams per day.[30] The European Food Safety Authority reported that up to 400 mg of caffeine per day (around 5.7 mg/kg of body mass per day) does not raise safety concerns for non-pregnant adults, while intakes up to 200 mg per day for pregnant and lactating women do not raise safety concerns for the fetus or the breast-fed infants.[31] A cup of coffee contains 80–175 mg of caffeine, depending on what "bean" (seed) is used, how it is roasted, and how it is prepared (e.g., drip, percolation, or espresso).[32] Thus it requires roughly 50–100 ordinary cups of coffee to reach the toxic dose. However, pure powdered caffeine, which is available as a dietary supplement, can be lethal in tablespoon-sized amounts.
Uses
Medical
Caffeine is used for both prevention[33] and treatment[34] of bronchopulmonary dysplasia in premature infants. It may improve weight gain during therapy[35] and reduce the incidence of cerebral palsy as well as reduce language and cognitive delay.[36][37] On the other hand, subtle long-term side effects are possible.[38]
Caffeine is used as a primary treatment for apnea of prematurity,[39] but not prevention.[40][41] It is also used for orthostatic hypotension treatment.[42][41][43]
Some people use caffeine-containing beverages such as coffee or tea to try to treat their asthma.[44] Evidence to support this practice is poor.[44] It appears that caffeine in low doses improves airway function in people with asthma, increasing forced expiratory volume (FEV1) by 5% to 18% for up to four hours.[45]
The addition of caffeine (100–130 mg) to commonly prescribed pain relievers such as paracetamol or ibuprofen modestly improves the proportion of people who achieve pain relief.[46]
Consumption of caffeine after abdominal surgery shortens the time to recovery of normal bowel function and shortens length of hospital stay.[47]
Caffeine was formerly used as a second-line treatment for ADHD. It is considered less effective than methylphenidate or amphetamine but more so than placebo for children with ADHD.[48][49] Children, adolescents, and adults with ADHD are more likely to consume caffeine, perhaps as a form of self-medication.[49][50]
Enhancing performance
Cognitive performance
Caffeine is a central nervous system stimulant that may reduce fatigue and drowsiness.[9] At normal doses, caffeine has variable effects on learning and memory, but it generally improves reaction time, wakefulness, concentration, and motor coordination.[51][52] The amount of caffeine needed to produce these effects varies from person to person, depending on body size and degree of tolerance.[51] The desired effects arise approximately one hour after consumption, and the desired effects of a moderate dose usually subside after about three or four hours.[4]
Caffeine can delay or prevent sleep and improves task performance during sleep deprivation.[53] Shift workers who use caffeine make fewer mistakes that could result from drowsiness.[54]
Caffeine in a dose dependent manner increases alertness in both fatigued and normal individuals.[55]
A systematic review and meta-analysis from 2014 found that concurrent caffeine and L-theanine use has synergistic psychoactive effects that promote alertness, attention, and task switching;[56] these effects are most pronounced during the first hour post-dose.[56]
Physical performance
Caffeine is a proven ergogenic aid in humans.[57] Caffeine improves athletic performance in aerobic (especially endurance sports) and anaerobic conditions.[57] Moderate doses of caffeine (around 5 mg/kg[57]) can improve sprint performance,[58] cycling and running time trial performance,[57] endurance (i.e., it delays the onset of muscle fatigue and central fatigue),[57][59][60] and cycling power output.[57] Caffeine increases basal metabolic rate in adults.[61][62][63] Caffeine ingestion prior to aerobic exercise increases fat oxidation, particularly in persons with low physical fitness.[64]
Caffeine improves muscular strength and power,[65] and may enhance muscular endurance.[66] Caffeine also enhances performance on anaerobic tests.[67] Caffeine consumption before constant load exercise is associated with reduced perceived exertion. While this effect is not present during exercise-to-exhaustion exercise, performance is significantly enhanced. This is congruent with caffeine reducing perceived exertion, because exercise-to-exhaustion should end at the same point of fatigue.[68] Caffeine also improves power output and reduces time to completion in aerobic time trials,[69] an effect positively (but not exclusively) associated with longer duration exercise.[70]
Specific populations
Adults
For the general population of healthy adults, Health Canada advises a daily intake of no more than 400 mg.[71] This limit was found to be safe by a 2017 systematic review on caffeine toxicology.[72]
Children
In healthy children, moderate caffeine intake under 400 mg produces effects that are "modest and typically innocuous".[73][74] As early as six months old, infants can metabolize caffeine at the same rate as that of adults.[75] Higher doses of caffeine (>400 mg) can cause physiological, psychological and behavioral harm, particularly for children with psychiatric or cardiac conditions.[73] There is no evidence that coffee stunts a child's growth.[76] The American Academy of Pediatrics recommends that caffeine consumption is not appropriate for children and adolescents and should be avoided.[77] This recommendation is based on a clinical report released by American Academy of Pediatrics in 2011 with a review of 45 publications from 1994 to 2011 and includes inputs from various stakeholders (Pediatricians, Committee on nutrition, Canadian Pediatric Society, Centers for Disease Control & Prevention, Food and Drug Administration, Sports Medicine & Fitness committee, National Federations of High School Associations).[77] For children age 12 and under, Health Canada recommends a maximum daily caffeine intake of no more than 2.5 milligrams per kilogram of body weight. Based on average body weights of children, this translates to the following age-based intake limits:[71]
| Age range | Maximum recommended daily caffeine intake |
|---|---|
| 4–6 | 45 mg (slightly more than in 355 ml (12 fl. oz) of a typical caffeinated soft drink) |
| 7–9 | 62.5 mg |
| 10–12 | 85 mg (about 1⁄2 cup of coffee) |
Adolescents
Health Canada has not developed advice for adolescents because of insufficient data. However, they suggest that daily caffeine intake for this age group be no more than 2.5 mg/kg body weight. This is because the maximum adult caffeine dose may not be appropriate for light-weight adolescents or for younger adolescents who are still growing. The daily dose of 2.5 mg/kg body weight would not cause adverse health effects in the majority of adolescent caffeine consumers. This is a conservative suggestion since older and heavier-weight adolescents may be able to consume adult doses of caffeine without experiencing adverse effects.[71]
Pregnancy and breastfeeding
The metabolism of caffeine is reduced in pregnancy, especially in the third trimester, and the half-life of caffeine during pregnancy can be increased up to 15 hours (as compared to 2.5 to 4.5 hours in non-pregnant adults).[78] Evidence regarding the effects of caffeine on pregnancy and for breastfeeding are inconclusive.[25] There is limited primary and secondary advice for, or against, caffeine use during pregnancy and its effects on the fetus or newborn.[25]
The UK Food Standards Agency has recommended that pregnant women should limit their caffeine intake, out of prudence, to less than 200 mg of caffeine a day – the equivalent of two cups of instant coffee, or one and a half to two cups of fresh coffee.[79] The American Congress of Obstetricians and Gynecologists (ACOG) concluded in 2010 that caffeine consumption is safe up to 200 mg per day in pregnant women.[26] For women who breastfeed, are pregnant, or may become pregnant, Health Canada recommends a maximum daily caffeine intake of no more than 300 mg, or a little over two 8 oz (237 mL) cups of coffee.[71] A 2017 systematic review on caffeine toxicology found evidence supporting that caffeine consumption up to 300 mg/day for pregnant women is generally not associated with adverse reproductive or developmental effect.[72]
There are conflicting reports in the scientific literature about caffeine use during pregnancy.[80] A 2011 review found that caffeine during pregnancy does not appear to increase the risk of congenital malformations, miscarriage or growth retardation even when consumed in moderate to high amounts.[81] Other reviews, however, concluded that there is some evidence that higher caffeine intake by pregnant women may be associated with a higher risk of giving birth to a low birth weight baby,[82] and may be associated with a higher risk of pregnancy loss.[83] A systematic review, analyzing the results of observational studies, suggests that women who consume large amounts of caffeine (greater than 300 mg/day) prior to becoming pregnant may have a higher risk of experiencing pregnancy loss.[84]
Adverse effects
Physiological
Caffeine in coffee and other caffeinated drinks can affect gastrointestinal motility and gastric acid secretion.[85][86][87] In postmenopausal women, high caffeine consumption can accelerate bone loss.[88][89]
Acute ingestion of caffeine in large doses (at least 250–300 mg, equivalent to the amount found in 2–3 cups of coffee or 5–8 cups of tea) results in a short-term stimulation of urine output in individuals who have been deprived of caffeine for a period of days or weeks.[90] This increase is due to both a diuresis (increase in water excretion) and a natriuresis (increase in saline excretion); it is mediated via proximal tubular adenosine receptor blockade.[91] The acute increase in urinary output may increase the risk of dehydration. However, chronic users of caffeine develop a tolerance to this effect and experience no increase in urinary output.[92][93][94]
Psychological
Minor undesired symptoms from caffeine ingestion not sufficiently severe to warrant a psychiatric diagnosis are common and include mild anxiety, jitteriness, insomnia, increased sleep latency, and reduced coordination.[51][95] Caffeine can have negative effects on anxiety disorders.[96] According to a 2011 literature review, caffeine use may induce anxiety and panic disorders in people with Parkinson's disease.[97] At high doses, typically greater than 300 mg, caffeine can both cause and worsen anxiety.[98] For some people, discontinuing caffeine use can significantly reduce anxiety.[99]
In moderate doses, caffeine has been associated with reduced symptoms of depression and lower suicide risk.[100] Two reviews indicate that increased consumption of coffee and caffeine may reduce the risk of depression.[101][102]
Some textbooks state that caffeine is a mild euphoriant,[103][104][105] while others state that it is not a euphoriant.[106][107]
Caffeine-induced anxiety disorder is a subclass of the DSM-5 diagnosis of substance/medication-induced anxiety disorder.[108]
Reinforcement disorders
Addiction
Whether caffeine can result in an addictive disorder depends on how addiction is defined. Compulsive caffeine consumption under any circumstances has not been observed, and caffeine is therefore not generally considered addictive.[109] However, some diagnostic models, such as the ICDM-9 and ICD-10, include a classification of caffeine addiction under a broader diagnostic model.[110] Some state that certain users can become addicted and therefore unable to decrease use even though they know there are negative health effects.[3][111]
Caffeine does not appear to be a reinforcing stimulus, and some degree of aversion may actually occur, with people preferring placebo over caffeine in a study on drug abuse liability published in an NIDA research monograph.[112] Some state that research does not provide support for an underlying biochemical mechanism for caffeine addiction.[27][113][114][115] Other research states it can affect the reward system.[116]
"Caffeine addiction" was added to the ICDM-9 and ICD-10. However, its addition was contested with claims that this diagnostic model of caffeine addiction is not supported by evidence.[27][117][118] The American Psychiatric Association's DSM-5 does not include the diagnosis of a caffeine addiction but proposes criteria for the disorder for more study.[108][119]
Dependence and withdrawal
Withdrawal can cause mild to clinically significant distress or impairment in daily functioning. The frequency at which this occurs is self-reported at 11%, but in lab tests only half of the people who report withdrawal actually experience it, casting doubt on many claims of dependence.[120] and most cases of caffeine withdrawal were 13% in the moderate sense. Moderately physical dependence and withdrawal symptoms may occur upon abstinence, with greater than 100 mg caffeine per day, although these symptoms last no longer than a day.[27] Some symptoms associated with psychological dependence may also occur during withdrawal.[2] The diagnostic criteria for caffeine withdrawal require a previous prolonged daily use of caffeine.[121] Following 24 hours of a marked reduction in consumption, a minimum of 3 of these signs or symptoms is required to meet withdrawal criteria: difficulty concentrating, depressed mood/irritability, flu-like symptoms, headache, and fatigue.[121] Additionally, the signs and symptoms must disrupt important areas of functioning and are not associated with effects of another condition.[121]
The ICD-11 includes caffeine dependence as a distinct diagnostic category, which closely mirrors the DSM-5's proposed set of criteria for "caffeine-use disorder".[119][122] Caffeine use disorder refers to dependence on caffeine characterized by failure to control caffeine consumption despite negative physiological consequences.[119][122] The APA, which published the DSM-5, acknowledged that there was sufficient evidence in order to create a diagnostic model of caffeine dependence for the DSM-5, but they noted that the clinical significance of the disorder is unclear.[123] Due to this inconclusive evidence on clinical significance, the DSM-5 classifies caffeine-use disorder as a "condition for further study".[119]
Tolerance to the effects of caffeine occurs for caffeine-induced elevations in blood pressure and the subjective feelings of nervousness. Sensitization, the process whereby effects become more prominent with use, occurs for positive effects such as feelings of alertness and wellbeing.[120] Tolerance varies for daily, regular caffeine users and high caffeine users. High doses of caffeine (750 to 1200 mg/day spread throughout the day) have been shown to produce complete tolerance to some, but not all of the effects of caffeine. Doses as low as 100 mg/day, such as a 6 oz (170 g) cup of coffee or two to three 12 oz (340 g) servings of caffeinated soft-drink, may continue to cause sleep disruption, among other intolerances. Non-regular caffeine users have the least caffeine tolerance for sleep disruption.[124] Some coffee drinkers develop tolerance to its undesired sleep-disrupting effects, but others apparently do not.[125]
Risk of other diseases
A neuroprotective effect of caffeine against Alzheimer's disease and dementia is possible but the evidence is inconclusive.[126][127]
Regular consumption of caffeine may protect people from liver cirrhosis.[128] It was also found to slow the progression of liver disease in people who already have the condition, reduce the risk of liver fibrosis, and offer a protective effect against liver cancer among moderate coffee drinkers. A study conducted in 2017 found that the effects of caffeine from coffee consumption on the liver were observed regardless of how the drink was prepared.[129]
Caffeine may lessen the severity of acute mountain sickness if taken a few hours prior to attaining a high altitude.[130] One meta analysis has found that caffeine consumption is associated with a reduced risk of type 2 diabetes.[131] Regular caffeine consumption may reduce the risk of developing Parkinson's disease and may slow the progression of Parkinson's disease.[132][133][23]
Caffeine increases intraocular pressure in those with glaucoma but does not appear to affect normal individuals.[134]
The DSM-5 also includes other caffeine-induced disorders consisting of caffeine-induced anxiety disorder, caffeine-induced sleep disorder and unspecified caffeine-related disorders. The first two disorders are classified under "Anxiety Disorder" and "Sleep-Wake Disorder" because they share similar characteristics. Other disorders that present with significant distress and impairment of daily functioning that warrant clinical attention but do not meet the criteria to be diagnosed under any specific disorders are listed under "Unspecified Caffeine-Related Disorders".[135]
Energy crash
Caffeine is reputed to cause a fall in energy several hours after drinking, but this is not well researched.[136][137][138][139]
Overdose
 | This section needs expansion with: practical management of overdose, see PMID 30893206. You can help by adding to it. (November 2019) |
Consumption of 1–1.5 grams (1,000–1,500 mg) per day is associated with a condition known as caffeinism.[141] Caffeinism usually combines caffeine dependency with a wide range of unpleasant symptoms including nervousness, irritability, restlessness, insomnia, headaches, and palpitations after caffeine use.[142]
Caffeine overdose can result in a state of central nervous system overstimulation known as caffeine intoxication, a clinically significant temporary condition that develops during, or shortly after, the consumption of caffeine.[143] This syndrome typically occurs only after ingestion of large amounts of caffeine, well over the amounts found in typical caffeinated beverages and caffeine tablets (e.g., more than 400–500 mg at a time). According to the DSM-5, caffeine intoxication may be diagnosed if five (or more) of the following symptoms develop after recent consumption of caffeine: restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation.[144]
According to the International Classification of Diseases (ICD-11), cases of very high caffeine intake (e.g. > 5 g) may result in caffeine intoxication with symptoms including mania, depression, lapses in judgment, disorientation, disinhibition, delusions, hallucinations or psychosis, and rhabdomyolysis.[143]
Energy drinks
High caffeine consumption in energy drinks (at least one liter or 320 mg of caffeine) was associated with short-term cardiovascular side effects including hypertension, prolonged QT interval, and heart palpitations. These cardiovascular side effects were not seen with smaller amounts of caffeine consumption in energy drinks (less than 200 mg).[78]
Severe intoxication
As of 2007[update] there is no known antidote or reversal agent for caffeine intoxication. Treatment of mild caffeine intoxication is directed toward symptom relief; severe intoxication may require peritoneal dialysis, hemodialysis, or hemofiltration.[140][145][146] Intralipid infusion therapy is indicated in cases of imminent risk of cardiac arrest in order to scavenge the free serum caffeine.[146]
Lethal dose
Death from caffeine ingestion appears to be rare, and most commonly caused by an intentional overdose of medications.[147] In 2016, 3702 caffeine-related exposures were reported to Poison Control Centers in the United States, of which 846 required treatment at a medical facility, and 16 had a major outcome; and several caffeine-related deaths are reported in case studies.[147] The LD50 of caffeine in rats is 192 milligrams per kilogram, the fatal dose in humans is estimated to be 150–200 milligrams per kilogram (2.2 lb) of body mass (75–100 cups of coffee for a 70 kg (150 lb) adult).[148][149] There are cases where doses as low as 57 milligrams per kilogram have been fatal.[150] A number of fatalities have been caused by overdoses of readily available powdered caffeine supplements, for which the estimated lethal amount is less than a tablespoon.[151] The lethal dose is lower in individuals whose ability to metabolize caffeine is impaired due to genetics or chronic liver disease.[152] A death was reported in 2013 of a man with liver cirrhosis who overdosed on caffeinated mints.[153][154]
Interactions
Caffeine is a substrate for CYP1A2, and interacts with many substances through this and other mechanisms.[155]
Alcoholedit
According to DSST, alcohol causes a decrease in performance on their standardized tests, and caffeine causes a significant improvement.[156] When alcohol and caffeine are consumed jointly, the effects of the caffeine are changed, but the alcohol effects remain the same.[157] For example, consuming additional caffeine does not reduce the effect of alcohol.[157] However, the jitteriness and alertness given by caffeine is decreased when additional alcohol is consumed.[157] Alcohol consumption alone reduces both inhibitory and activational aspects of behavioral control. Caffeine antagonizes the activational aspect of behavioral control, but has no effect on the inhibitory behavioral control.[158] The Dietary Guidelines for Americans recommend avoidance of concomitant consumption of alcohol and caffeine, as taking them together may lead to increased alcohol consumption, with a higher risk of alcohol-associated injury.
Tobaccoedit
Smoking tobacco increases caffeine clearance by 56%.[159] Cigarette smoking induces the cytochrome P450 1A2 enzyme that breaks down caffeine, which may lead to increased caffeine tolerance and coffee consumption for regular smokers.[160]
Birth controledit
Birth control pills can extend the half-life of caffeine, requiring greater attention to caffeine consumption.[161]
Medicationsedit
Caffeine sometimes increases the effectiveness of some medications, such as those for headaches.[162] Caffeine was determined to increase the potency of some over-the-counter analgesic medications by 40%.[163]
The pharmacological effects of adenosine may be blunted in individuals taking large quantities of methylxanthines like caffeine.[164] Some other examples of methylxanthines include the medications theophylline and aminophylline, which are prescribed to relieve symptoms of asthma or COPD.[165]
Pharmacologyedit
Pharmacodynamicsedit
In the absence of caffeine and when a person is awake and alert, little adenosine is present in CNS neurons. With a continued wakeful state, over time adenosine accumulates in the neuronal synapse, in turn binding to and activating adenosine receptors found on certain CNS neurons; when activated, these receptors produce a cellular response that ultimately increases drowsiness. When caffeine is consumed, it antagonizes adenosine receptors; in other words, caffeine prevents adenosine from activating the receptor by blocking the location on the receptor where adenosine binds to it. As a result, caffeine temporarily prevents or relieves drowsiness, and thus maintains or restores alertness.[5]
Receptor and ion channel targetsedit
Caffeine is an antagonist of adenosine A2A receptors, and knockout mouse studies have specifically implicated antagonism of the A2A receptor as responsible for the wakefulness-promoting effects of caffeine.[166] Antagonism of A2A receptors in the ventrolateral preoptic area (VLPO) reduces inhibitory GABA neurotransmission to the tuberomammillary nucleus, a histaminergic projection nucleus that activation-dependently promotes arousal.[167] This disinhibition of the tuberomammillary nucleus is the downstream mechanism by which caffeine produces wakefulness-promoting effects.[167] Caffeine is an antagonist of all four adenosine receptor subtypes (A1, A2A, A2B, and A3), although with varying potencies.[5][166] The affinity (KD) values of caffeine for the human adenosine receptors are 12 μM at A1, 2.4 μM at A2A, 13 μM at A2B, and 80 μM at A3.[166]
Antagonism of adenosine receptors by caffeine also stimulates the medullary vagal, vasomotor, and respiratory centers, which increases respiratory rate, reduces heart rate, and constricts blood vessels.[5] Adenosine receptor antagonism also promotes neurotransmitter release (e.g., monoamines and acetylcholine), which endows caffeine with its stimulant effects;[5][168] adenosine acts as an inhibitory neurotransmitter that suppresses activity in the central nervous system. Heart palpitations are caused by blockade of the A1 receptor.[5]
Because caffeine is both water- and lipid-soluble, it readily crosses the blood–brain barrier that separates the bloodstream from the interior of the brain. Once in the brain, the principal mode of action is as a nonselective antagonist of adenosine receptors (in other words, an agent that reduces the effects of adenosine). The caffeine molecule is structurally similar to adenosine, and is capable of binding to adenosine receptors on the surface of cells without activating them, thereby acting as a competitive antagonist.[169]
In addition to its activity at adenosine receptors, caffeine is an inositol trisphosphate receptor 1 antagonist and a voltage-independent activator of the ryanodine receptors (RYR1, RYR2, and RYR3).[170] It is also a competitive antagonist of the ionotropic glycine receptor.[171]
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