People rarely die from caffeine. But recent headlines about Panera’s Charged Lemonade have left some wondering if their favorite stimulant could be putting them in harm’s way.

 

Dangers and deaths are dose-dependent

Tolerance to caffeine varies, but toxicity symptoms, including seizure and cardiac arrhythmia, don’t typically occur until plasma concentrations reach 15 mg/L or higher, according to the authors of a systematic review of caffeine-related death.

Cappelletti S, Piacentino D, Fineschi V, et al. Caffeine-related deaths: manner of deaths and categories at risk. Nutrients. 2018;10(5):611.

 

Aside from the unpleasant effects of “caffeinism,” such as anxiety, insomnia, and tremors, it is the cardiovascular effects of supraventricular and ventricular tachyarrhythmias that are the most lethal. The cause of death involving caffeine intoxication is usually documented as ventricular fibrillation.

 

Populations at risk for caffeine-fueled fatalities

 

The systematic review identified 92 cases of caffeine-related death. In 36 cases, suicide was identified as the cause of death. The second known cause of death was through accidental overdoses with weight loss products and other supplements. The researchers also found two reports of intentional poisonings of infants related to child abuse. 

 

 

Deaths among babies and children

One of the two infant cases in the review was a 14-month-old child who presented with high levels of theophylline, delayed weight gain, chronic iron deficiency anemia, thymic involution, and severe trauma to the spleen and ribs, indicating abuse and caffeine toxicity. There was also evidence of prolonged vomiting. The amount or method of caffeine intake, however, was unknown.

In the other case, a 5-month-old baby was given caffeine tablets by his abusive father. The infant was initially admitted with persistent tachycardia and caffeine levels of 5 to 12 mg/L. He was later readmitted with subarachnoid hemorrhages and died within days.

Despite prompt medical intervention, these children did not survive.

 

Special considerations for psychiatric populations

Given that suicide was responsible for the largest amount of caffeine deaths in the review, it’s not surprising that people with psychiatric conditions are at heightened risk. Depression was by far the most noted condition, followed by alcohol dependence, sleep disorders, drug dependence, and eating disorders. Several of those who died by suicide with caffeine had previous suicide attempts.

Case reports have described life-saving interventions after attempted suicide with caffeine. In one case, a 47-year-old man ingested 70 g of pure anhydrous caffeine powder. After two episodes of ventricular fibrillation, his life was saved using defibrillation, tracheal intubation, and IV esmolol and norepinephrine.

Grémain V, Chevillard L, Saussereau E, et al. Massive suicidal ingestion of caffeine: a case report with investigation of the cardiovascular effect/concentration relationships. Clinical Toxicology. 2021;59(10):937–941.

In another, a 23-year-old man developed complications after ingesting 24 g of caffeine. He recovered after being resuscitated and provided hemodialysis.

Khan S, Babu K, Sidhu R, et al. Caffeine intoxication treated with hemodialysis. Seminars in Dialysis. 2023;36(5):414–418.

 

 

 

Caffeine regulations for athletes and others

Athletes described in the review ranged between 18 to 44 years old, including two amateur bodybuilders, a basketball player, and a wrestler. In these cases, excessive caffeine combined with strenuous activity led to myocardial ischemia and cardiac arrest by coronary vasospasm.

The aggressive marketing of energy drinks, often glamorized by connections to extreme sports, has led to a dramatic spike in caffeine intake among young adults and adolescents.

Costantino A, Maiese A, Lazzari J, et al. The dark side of energy drinks: a comprehensive review of their impact on the human body. Nutrients. 2023;15(18):3922.

Despite increasing concerns about the acute and chronic effects of caffeine toxicity, safety regulations and accountability are slow to follow.

 

Between 2022 and 2023, three individuals under age 45 suffered cardiac arrest after consuming Panera’s Charged Lemonade.

Walrath-Holdridge M. Panera Charged Lemonade linked to alleged deaths, lawsuits: everything that's happened so far. USA Today. January 22, 2024.

These incidents included two people who died and one who reported lasting complications. Currently, two lawsuits are underway, and Panera has issued new warning labels and restrictions on self service.