<< Back to News

System Formulary Update
Caffeine Citrate Oral Solution

Situation

Upon implementation of the non-selective phosphodiesterase inhibitors class standardization, it was identified that there are varying practices regarding use of caffeine citrate oral solution.

Background

At the time of the evaluation, caffeine citrate 20 mg/mL (3 mL) oral solution (vial) specifically the commercial product was approved to be on System Formulary. It was initially unclear in the data evaluated that there were varying practices across the system regarding oral administration of caffeine citrate. Upon further review, the varying practices identified included:

• Use of the commercial caffeine citrate 20 mg/mL (3 mL) oral solution (vial) for oral administration
• Use of the commercial caffeine citrate 20 mg/mL (3 mL) intravenous solution (vial) for oral administration (Rex)
• Use of an extemporaneous caffeine citrate 20 mg/mL (480 mL) oral solution for oral administration (Medical Center)

While all practices are appropriate, there have been reports from the Institute of Safe Medication Practices (ISMP) regarding look-alike errors occurring due to the similar labeling of commercial oral and intravenous solution products.

These safety concerns led to Medical Center and Rex adopting practices which avoid use of the commercial oral solution product.

Assessment/Recommendation

Changes effective: Tuesday, June 29, 2021

System P&T voted to include the following products on the UNC Health System Drug Formulary:

• Caffeine citrate 20 mg/mL oral solution (extemporaneously compounded)

As a result, the following products will be removed from the drug formulary:

• Commercial caffeine citrate 20 mg/mL (3 mL) oral solution (vial)

Note: Stock of these formulary products may vary at individual entities. Also, sites may opt to administer the commercial intravenous solution product orally as well.