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The role of the clinical laboratory in adverse effects related to energy drinks Maria Teresa Aguirre, MS, MT, ASCP University of Texas Rio Grande Valley August 2, 2016 Objectives List the components of energy drinks Describe the benefits provided by energy drinks, as perceived Describe the benefits and adverse effects of caffeine Describe current caffeine consumption trends in the U.S. Describe caffeine and its possible adverse effects in mental health, sleep disturbances, and athletics Describe the patient profile and presentation due to caffeine toxicity or adverse effects due to energy drink consumption Discuss the lab tests best suited to detect possible caffeine toxicity History and basic ingredients Brief History • 1960’s • Taisho Pharmaceuticals • Lipovitan D as a medicinal tonic for increased energy Basic ingredients Dietary Supplements Ginseng Guarana • 1986 Red Bull invented in Austria by Dietrich Mateschitz Taurine • 1997 Red Bull introduced to the U.S. Sugar • 2002 Monster was created by Hansen Naturals • 2005-2006 energy drinks became widely popular Caffeine Product name Ginseng (mg) Taurine (mg) Guarana (mg) Caffeine (mg) Sugar (g) Arizona Caution Extreme 100 Energy Shot 1000 0 100 33 Cocaine 0 750 25 280 18 Full Throttle* 90 605 0.70 72 29 Monster 200 1000 * 92 27 Pimp Juice 0 7 100 81 34 Red Bull 0 1000 0 80 27 Rockstar Energy 25 946 200 80 27 Rockstar Juiced 25 1000 25 80 21 SoBe No Fear* 50 1000 50 87 33 SoBe Adrenaline Rush 50 1000 50 79 33 Spike Shooter 0 0 0 300 0 Ingredients of selected energy drinks based on 8.0 – 8.4-ounce servings *Part of an “Energy Blend” ingredient Clauson, KA, Shields, KM, et al. Safety issues associated with commercially available energy drinks. JAPha. May/June 2008; 48:3. What makes them so energizing? Ginseng Used for treatment of certain disorders Contributes to caloric load Below therapeutic levels in energy drinks One 8 oz can has as much sugar (32 g) as the U.S. recommended daily allowance Sugar Guarana Caffeine Active ingredient in energy drinks A plant native to South America Has many beneficial effects High concentrations of caffeine Ill effects depend on a complex combination of state of health and sensitivity to caffeine In large doses can cause death Taurine Naturally occurring amino acid found in meat, seafood, and dairy Also used therapeutically in certain disorders Studies have not shown that taurine acts as an energy enhancing supplement Energy drink labels The Nutrition Facts Panel on food labels is not required by FDA to include caffeine content, only nutrients Caffeine is not a nutrient Energy products such as drinks and powders have not been clearly defined by US law In a study by Consumer Reports in 2012 27 of the top energy drinks were analyzed Of those products that listed caffeine, the content was more than 20% over the amount stated on the label The remaining 11 products did not state the amount of caffeine contained Caffeine – benefits and adverse effects Benefits Increase in alertness and concentration Increased concentration in conditions requiring alertness at or near the circadian alertness trough May produce pleasant effects such as elation, peacefulness, pleasantness Moderate consumption may prevent mental health disorders Associated with weight loss and reduced risk of Type II diabetes Reduced risk of Parkinson’s disease Adverse effects Overstimulation Excitability Nervousness Panic attacks Tremors Palpitations Arrhythmias Cardiac arrest Sinus tachycardia Ventricular tachycardia Caffeine Normal and lethal dose FDA lists ≤400 mg/day as safe consistent with World Health Organization (WHO) recommendations (2013) “Caffeinism” is defined as adverse reactions due to consumption of caffeine in doses of 500 mg/day or more, usually 1500-2000 mg/day (WHO, 2013; Gilliland and Andress, 1981). Fatal doses usually result from ventricular tachycardia and occurs at doses of 100 mg/kg body weight (Szpak and Allen, 2012). Example: 150 lbs = 68 kg x 100 mg caffeine = 6800 mg Fatalities may occur at lower doses depending on caffeine sensitivity and overall cardiac health and tolerance to caffeine. Most people “self-regulate” consumption throughout the day (Szpak and Allen, 2012). Currently consumed in US Based on two large studies Kantar Worldpanel Beverage Consumption Panel Study conducted October 2010 – October 2011 (37,602 consumers) The National Health and Nutrition Examination Surveys (NHANES) conducted 2001-2010 Average consumption is 165 mg/day Population with highest tolerance and intake is 40-65 years of age, and increases with age Main beverage consumed is coffee Percentage of those using energy drinks and shots is low <10% and consists mostly of (Somogoyi, 2010): Young adults Teenagers College students Athletes Military personnel Risk factors These risk factors coupled with caffeine use increase the likelihood of adverse effects: Age Sex Mental health Lack of sleep Use for enhanced athletic performance Risk factors – age and sex Energy drink consumers are most likely to be men in the 18-34 year age group (Packaged Facts, 2013) Adolescent males are more likely to partake in risky behavior than females of any age and males of any other age group. This difference has been explained by “gender-related neurophysiological vulnerability” or the differences in brain development between the sexes (Giedd, et al.). Excessive energy drink use is considered risky behavior and is more common in those predisposed to this type of behavior. This validates findings published by the Drug Abuse Warning Network, a public health surveillance system (SAMHSA, 2013), for example: Emergency room department visits involving energy drinks doubled from 10,068 in 2007 to 20,783 in 2011 Visits involving “misuse or abuse” of these drinks nearly doubled from 3,060 in 2007 to 6090 in 2011 accounting for approximately 60% of the visits Males account for approximately two-thirds or more of these visits. Of the 20,783 reported visits in 2011, approximately half of these visits (8,652) involved another psychoactive substance (SAMHSA, 2013). No urine drug tests were conducted, this combination may be larger than reported. Other risk factors -Caffeine and mental health Latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists various disorders related to caffeine Associated with adverse psychological reactions in people with psychiatric illnesses In patients with no reported history, caffeine and ginseng have been linked with initiating manic episodes Patients with undiagnosed or undercontrolled psychiatric illnesses are at risk in overconsumption of caffeine In a study by Baethge, et al. in 2009 Patients diagnosed with bipolar affective disorder who consumed moderate amounts of caffeine showed “increased rates of suicidal acts and behavior”. Case in point: A young man with bipolar disorder who had been maintained with lithium therapy for 5 years had a manic episode requiring hospitalization after drinking 3 cans of Red Bull on 2 days during the week before admission (Kilgore et al., 2011) Other risk factors -Caffeine and lack of sleep Chronic sleep disturbance health risks Mood disorders (Oyahon et al., 2003) Depression, psychosis, mania (Szpak and Allen, 2012) Depressed immune function (Rogers et al., 2001) Age-related cognitive decline (Jelicic et al., 2002) Metabolic syndrome/obesity/diabetes (Van Cauter et al., 2008) Heart disease (Sands-Lincoln et al., 2013) Cancer (Sigurdardottir et al., 2013) Caffeine and reports of stress Sleepiness Insufficient sleep (Toblin, et al. 2012) A case of caffeine toxicity A 20 year old female college student went into cardiac arrest while attending a party with her new boyfriend She was known as a successful student, with good grades and involvement in various campus activities Brought to the ER unresponsive, while undergoing resuscitative efforts, the ER staff had questions about her history which he was unable to answer Remarkable lab results included negative drug screen and a glucose level > 500 mg/dl Parents denied that she had any health problems or history of diabetes Boyfriend became a suspect of foul play Patient recovered and reported that she had consumed 5 energy drinks that day A case of sleep deprivation and suicide attempt linked to excessive caffeine intake A 28 year old professional boxer Fit without medical problems Unremarkable personal history No previous need for psychiatric services No episodes of depression or suicidal thoughts Family history A brother committed suicide by hanging following a previous attempt 8 years prior Another brother died of alcohol and drug overdose Father alcoholic following his wife’s death A case of sleep deprivation and suicide attempt linked to excessive caffeine intake Scenario Security guard – night shift Two days prior to working 2 consecutive nights drank 14 (8 ounces) cans of energy drink throughout day and evening to stay awake and alert Did not sleep for 72 hours; appetite poor Denied any physical or mental symptoms due to lack of sleep Suicide attempt Before his second shift had an argument with his partner Came home and argued more arose at 8:00 a.m. Went to garden shed and hung himself Was found unresponsive by his partner A case of sleep deprivation and suicide attempt linked to excessive caffeine intake Emergency Room Was taken unresponsive and was resuscitated Taken to ICU referred to psychiatric services Had no memory of the event He completely stopped using energy drinks May have been undergoing effects of caffeine withdrawal prior to suicide attempt Withdrawal symptoms of caffeine Anxiety Depressed mood Headache and tiredness (Szpak and Allen, 2012). Cardiac arrest in athletes Many incidents have been reported of cardiac arrest or death in athletes following a strenuous athletic event and consumption of energy drinks beforehand. Contribution of excessive caffeine Dehydration Loss of electrolytes Triggering of arrhythmias (Mehta, et al., 1997; Berger and Alford, 2009) Cardiac arrest in a young man after motocross race 28 year old male amateur motocross rider suffered cardiac arrest after race Had consumed 7-8 cans of an energy drink within 7 hours before race (640 mg caffeine) Had no family history of cardiac disease or unexplained syncope Labs Tropinin I 0.24 mmol/L (<0.05 mmol/L) Troponin I peaked at 12.2 mmol/L upon transfer to cardiac unit Potassium 3.0 mmol/L (3.6 -5.4 mmol/L) Potassium 4.0 mmol/L upon transfer to cardiac unit Urine drug test results negative Discharge Discharged after 6 days Final diagnosis coronary vasospasm due to ingestion of stimulants in the presence of hypokalemia and physical exertion due to diuretic effect of caffeine Dangers of mixing alcohol with energy drinks Biggest danger is energy drink masks state of inebriation Blood alcohol levels are elevated in spite of “alertness” experienced Motor skills and visual impairment due to alcohol are still present Caffeine, sleep impairment and lifestyle Lifestyles in the 21st century Forego sleep Push harder at work Social life May be due to immediacy of communication Electronic Social media “Social jetlag” Neurobehavioral deficits caused by lack of sleep (Wittman et al., 2006) Caffeine reduces sleep Continued sleep deficit will result in shortened lifespan Breakdown of biological processes “Blacking out” Patient profile Young males and females with low caffeine tolerance Those with diagnosed and undiagnosed psychiatric illnesses Those lacking sleep Young adult males Teenagers Shift work College students Studying Needing to stay alert or awake Athletes Military personnel Those mixing alcohol or drugs with energy drinks Laboratory tests for caffeine toxicity David Yew MD, China Burns, et al. (March, 2014) Patient’s signs and symptoms should guide laboratory order Hemodynamically stable Mild symptoms Able to give a clear history of caffeine ingestion No lab studies are indicated Hemodynamic instability Dysrhythmias Seizures Altered mental states Lab studies required Laboratory tests for caffeine toxicity David Yew MD, China Burns, et al. (March, 2014) CBC – evaluate for infection Mild leukocytosis (11,000 to 16,000/mL) can be present in caffeine toxicity, however exclude infection UA – dipstick may give rapid indication of rhadomyolysis, myoglobinuria, or both Glycosuria and ketonuria are also common findings Serum electrolytes, glucose, BUN, and creatinine Rapid urine drug screen Serum alcohol Osmolality Serum pregnancy in all women of childbearing age Serum caffeine (not recommended) Serum theophylline Pay close attention to potassium and anion gap Hypokalemia is classic feature of caffeine overdose Check for other treatable toxins such as acetaminophen, salicylates Total CK for rhabdomyolysis occasionally associated with severe caffeine toxicity Include CK-MB and troponin if myocardial ischemia is suspected May have levels in the therapeutic range of 10 – 20 mg/L In summary… Energy drinks may have much more caffeine than stated on the label Caffeine tolerance is different for different people and depends on Daily consumption Sensitivity to caffeine Even moderate amounts of caffeine can cause negative effects Loading up an energy drinks to stay awake or enhance physical performance can be potentially life-threatening Lack of sleep and history of mental illness can exacerbate the negative effects of caffeine Know your limits Questions? Thank you!
