Syrup of ipecac
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Syrup of ipecac (//), commonly referred to as ipecac, is a drug that was once used as a cough syrup and to induce vomiting. It is obtained from the dried rhizome and roots of Carapichea ipecacuanha from which it derives its name.
The commercial preparation of ipecac consists of 1/14 of an alcoholic extract of the roots and rhizomes of ipecac root. The rest is composed of glycerin, sugar syrup, and methylparaben. Ipecac root itself is a poison, but in this diluted form, its ability to induce immediate vomiting means that the syrup is seldom fatal.
Ipecac was used in cough mixtures as an expectorant or an emetic from the 18th until the early 20th century. Ipecac and opium were used to produce Dover's powder, which was used in syrup form. Ipecac syrup is still used to induce vomiting, though it is no longer widely recommended.
Pediatricians once recommended ipecac be kept in the home as a ready emetic for use in cases of accidental poisoning. Current guidelines from the American Academy of Pediatrics, however, strongly advise against this and in fact recommend the disposal of any syrup of ipecac present in the home. Many toxicological associations have also issued position papers recommending against its use as a first-line treatment for most ingested poisons, because of a lack of evidence that syrup of ipecac actually helps improve the outcome in cases of poisoning. Moreover, accidental overdose of ipecac can result when administered in the home. When dealing with poisoning cases in hospital, it became difficult to obtain a differential diagnosis when syrup of ipecac had been administered, as this can add further symptoms.
A 2005 review by an HRSA-funded scientific panel concluded that vomiting alone does not reliably remove poisons from the stomach. The study suggested that indications for use of ipecac syrup were rare, and patients should be treated by more effective and safer means. Additionally, its potential side effects, such as lethargy, can be confused with the poison's effects, complicating diagnosis. The use of ipecac may also delay the use of other treatments (e.g., activated charcoal, whole bowel irrigation, or oral antidotes) or make them less effective.
Ipecac has been used by individuals with bulimia nervosa as a means to achieve weight loss through induced vomiting. Repeated use in this manner is believed to cause damage to the heart and muscles, which can ultimately result in the user's death. Misuse of ipecac has been blamed for the death of well-known singer Karen Carpenter in 1983. It has also been used as an agent for Münchausen syndrome by proxy.
Mechanism of action
The actions of ipecac are mainly those of major alkaloids, emetine (methylcephaeline) and cephaeline. They both act locally by irritating the gastric mucosa and centrally by stimulating the medullary chemoreceptor trigger zone to induce vomiting.
Ipecac has been found to have minimal health benefits, and ultimately ineffective at purging the body of poisonous substances, and as such global production of the syrup has been stopped. As the ASHP puts it, "Ipecac syrup is no longer recommended for routine management of outpatient ingestions of medications or other chemicals." Humco discontinued their ipecac syrup in 2010, and Paddock Laboratories, the only remaining manufacturer, stopped manufacturing ipecac syrup.
A heavily cited position statement outlines critical details of its effectiveness:
"In experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned. There is insufficient data to support or exclude ipecac administration soon after poison ingestion. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. Ipecac should not be administered to a patient who has a decreased level or impending loss of consciousness or who has ingested a corrosive substance or hydrocarbon with high aspiration potential."
- Gardner, H. G.; American Academy Of Pediatrics Committee On Injury, Violence (2007), "Office-Based Counseling for Unintentional Injury Prevention", Pediatrics 119 (1): 202–6, doi:10.1542/peds.2006-2899, PMID 17200289
- American Academy Of Pediatrics Committee On Injury, Violence (2003), "Poison Treatment in the Home", Pediatrics 112 (5): 1182–5, doi:10.1542/peds.112.5.1182, PMID 14595067
- American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists (2004), "Position Paper: Ipecac Syrup", Clinical Toxicology 42 (2): 133–43, doi:10.1081/CLT-120037421, PMID 15214617
- Bateman, D N (1999), "Gastric decontamination—a view for the millennium", Emergency Medicine Journal 16 (2): 84–6, doi:10.1136/emj.16.2.84, PMC 1343284, PMID 10191436
- Manoguerra, Anthony; Cobaugh, Daniel; Panel, Guidelines for the Management of Poisoning Consensus Panel (2005), "Guideline on the Use of Ipecac Syrup in the Out-of-Hospital Management of Ingested Poisons", Clinical Toxicology 43 (1): 1–10, doi:10.1081/CLT-200046735, PMID 15732439
- Silber, Tomas J. (2005), "Ipecac syrup abuse, morbidity, and mortality: Isn't it time to repeal its over-the-counter status?", Journal of Adolescent Health 37 (3): 256–60, doi:10.1016/j.jadohealth.2004.08.022, PMID 16109351
- Schmidt R (24 October 2010), "Karen Carpenter's tragic story", The Guardian
- Shannon, M. (2003), "The Demise of Ipecac", Pediatrics 112 (5): 1180–1, doi:10.1542/peds.112.5.1180, PMID 14595066
- "Ipecac Syrup". Discontinued Drug Bulletin.
- Krenzelok, EP; McGuigan, M; Lheur, P (1997), "Position Statement: Ipecac Syrup", Clinical Toxicology 35 (7): 699–709, doi:10.3109/15563659709162567, PMID 9482425