What is ipecac

Ipecac medical use has virtually vanished. If you still have old bottles of syrup of ipecac in your home, throw them away ¹. Don’t give syrup of ipecac or do anything to induce vomiting. Expert groups, including the American Association of Poison Control Centers ² and the American Academy of Pediatrics ³, ⁴, no longer endorse using ipecac in children or adults who have taken pills or other potentially poisonous substances. No good evidence proves its effectiveness, and it often can do more harm than good.

Syrup of ipecac should not be administered routinely in the management of poisoned patients ⁵. Paradoxically, ipecac is itself a poison. Because it promptly induces vomiting, there is little concern for its intrinsically poisonous nature. 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 are insufficient data to support or exclude ipecac administration soon after poison ingestion ⁵. 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 ⁵. A review of the literature since the preparation of the 1997 Ipecac Syrup Position Statement revealed no new evidence that would require a revision of the conclusions of that Statement ⁵.

Beginning with the 1997 position statement by the American Academy of Clinical Toxicology position statement on ipecac syrup in poisonings, ipecac had fewer uses. “Syrup of ipecac should not be administered routinely in the management of poisoned patients. 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 are 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” ⁶, ⁵.

The 2013 position paper update on ipecac syrup for gastrointestinal decontamination gave no more encouragement: “… there remains no convincing evidence from clinical studies that ipecac improves the outcome of poisoned patients. Furthermore, the availability of ipecac is rapidly diminishing. Conclusions. The routine administration of ipecac at the site of ingestion or in the emergency department should be avoided. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. There is not sufficient evidence to warrant any change in the previous Ipecac position papers. There are, however, insufficient data to support or exclude ipecac administration soon after ingestion of some specific poisons in rare situations” ⁷.

Ipecac isn’t given any more for medical reasons; it used to be dosed 15 ml of a 1/14 preparation.

In a different realm, ipecac and its derivatives inhibit protein synthesis. Its components have found some use as antimicrobials with activity against amoebas and helminths. For this use, however, it is administered parenterally (injection) ⁸.

What does ipecac do

Ipecac is commonly made from alcohol extraction of the dried root of Cephaelis ipecacuanha and Cephaelis acuminata, and its active alkaloids are emetine and cephaeline ⁹. This extract is often mixed with glycerin, sugar (syrup), and methylparaben. The active ingredients are plant alkaloids, cephaeline, and methyl-cephaeline (emetine). Cephaeline is twice as potent an emetic as emetine, and both alkaloids induce vomiting by a central action. Emetine, a component of ipecac, has been found to have antihelminthic and antiamoebic properties. In addition, emetine has a direct irritant action on the gastric mucosa, which usually causes vomiting within 30 minutes of a patient being given ipecacuanha; later vomiting results from the central action of both alkaloids. Ipecac syrup effectively induces emesis in children of any age ¹⁰ and in adults ¹¹. Ipecac medical use has virtually vanished. However, ipecac abuse is increasing as a purgative in eating disorders ⁸.

Ipecac irritates the stomach lining and chemically stimulates the CRTZ (ChemoReceptor Trigger Zone) to induce near-immediate vomiting. For some years, this was the justification for its recommendation for administering in the case of orally ingested poisons. However, clinical research began to call this into question.

Ipecac is rarely useful for most poisonings. It is unsuccessful at removing any great quantities of ingested poisons unless delivered in the first few minutes post ingestion; even then, the result is variable and rather poor (see the mechanism of action). Its effect of uncontrolled vomiting delays other gastrically administered antidotes (e.g., activated charcoal) by one to two hours. A controlled airway is a must. If the patient demonstrates signs of toxicity that include sedation or an inability to maintain their airway, ipecac will not only create a risk of aspiration of vomited material, it will almost certainly be ineffectual as the drug is already absorbed (as demonstrated by neurologic suppression).

Ipecac side effects

Ipecac induces vomiting with all its attendant problems, including delays in the administration of gastrointestinal (GI) medication. This leads to delays in activated charcoal, amongst others. Prolonged vomiting is uncomfortable and can lead to electrolyte disorders. Additionally, it doesn’t do a good job of gastric emptying.

Emetine blocks the 40-S ribosomal unit causing a decrease in protein production. This inhibition of protein synthesis is a feature shared with several classes of antibiotics (macrolides).

Contraindications

Ipecac, if used with a caustic ingestion, causes a return: if it burned going down, it burns coming up. It should not be used when a patent airway is not assured for the entire duration of action, one to two hours. In general, if signs of absorption and toxicity are demonstrated, the administration is likely to be futile, ensuring risk (chance) of harm without risk of benefit.

As ipecac interferes with protein generation and may aggravate myopathy, it should be used with caution in patients with muscular function disorders.

Ipecac toxicity

Ipecac appears to have little innate toxicity. “Considering that over 3 million patients received therapeutic doses of ipecac during the 14-year period of 1983 through 1996, ipecac appears to have a high margin of safety. The potential complications of the therapeutic use of ipecac are well-documented, but serious sequelae occur rarely. An important concern is that the use of ipecac can delay the administration of activated charcoal by one to two hours” ².

Ipecac has very little accepted medical use in toxicology. If administered in the first few minutes after an oral ingestion of a non-corrosive, nonvolatile substance which, if absorbed and metabolized, may cause harm, Ipecac may remove an uncertain amount of the ingested by vomiting it up. The amount removed is very uncertain.

References

1. Office-Based Counseling for Unintentional Injury Prevention. H. Garry Gardner. Pediatrics Jan 2007, 119 (1) 202-206; DOI: 10.1542/peds.2006-2899 http://pediatrics.aappublications.org/content/119/1/202
2. Höjer J, Troutman WG, Hoppu K, Erdman A, Benson BE, Mégarbane B, Thanacoody R, Bedry R, Caravati EM., American Academy of Clinical Toxicology. European Association of Poison Centres and Clinical Toxicologists. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar;51(3):134-9. https://www.ncbi.nlm.nih.gov/pubmed/23406298
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5. Position paper: Ipecac syrup. J Toxicol Clin Toxicol. 2004;42(2):133-43. https://www.ncbi.nlm.nih.gov/pubmed/15214617
6. American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. Position Statement: Ipecac Syrup (J Toxicol Clin Toxicol 1997 ; 35 : 699 – 709
7. J. Höjer, W. G. Troutman, K. Hoppu, A. Erdman, B. E. Benson, B. Mégarbane, R. Thanacoody, R. Bedry & E. M. Caravati (2013) Position paper update: ipecac syrup for gastrointestinal decontamination, Clinical Toxicology, 51:3, 134-139, DOI:10.3109/15563650.2013.770153 http://www.clintox.org/wp-content/uploads/2016/04/Position-Statement-Ipecac-Syrup-1.pdf
8. Benzoni T, Gossman WG. Ipecac. [Updated 2017 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448075
9. Syrup of ipecacuanha: is it really useful?. British Medical Journal 22 Nov. 1986, vol 293, 6558, page 1321-22
10. Krenzelok EP, Dean BS. Syrup of ipecac in children less than one year of age. Clinical Toxicology 1985;23:171-6.
11. Lawson GR, Craft AW, Jackso RH. Changing pattern of poisoning in children in Newcastle, 1974-81. BrMedJ 1983;287:15-7.