Contact Us    Contact Us     |     Feedback
MOBILE VIEW  | 

LAXATIVES-SALINE

Export To Excel

Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Saline laxatives are generally given by mouth producing catharsis with soft or fluid stools. The citrates, sulfates, and tartrates of sodium or potassium are the usual agents used (Sollman, 1957).

Specific Substances

    A) CARLSBAD SALT ARTIFICIAL (synonym)
    1) CAS 8007-49-6
    POTASSIUM BITARTRATE (synonym)
    1) Acid potassium tartrate
    2) Cream of Tartar
    3) Cremor tartari
    4) E336
    5) Faecla
    6) Faecula
    7) Kalium Hydrotartaricum
    8) Potassium acid tartrate
    9) Potassium hydrogen tartrate
    10) Purified Cream of Tartar
    11) Tartarus Depuratus
    12) Weinstein
    13) Molecular Formula: C4-H5-K-O6
    14) CAS 868-14-4
    POTASSIUM SODIUM TARTRATE (synonym)
    1) E337
    2) Kalium-natrium Tartaricum
    3) Rochelle Salt
    4) Seignette Salt
    5) Sodii et Potassii Tartras
    6) Sodium Potassium Tartrate
    7) Tartarus Natronatus
    8) Molecular Formula: C4-H4-K-Na-O6
    9) CAS 304-59-6 (anhydrous)
    POTASSIUM SULFATE (synonym)
    1) 515
    2) Kalium Sulfuricum
    3) Molecular Formula: K2-S-O4
    4) Potassii Sulphas
    5) Tartarus Vitriolatus
    6) CAS 7778-80-5
    SEIDLITZ MIXTURE (synonym)
    1) CAS 8014-63-9
    SODIUM CITRATE (synonym)
    1) E331
    2) Natrii Citras
    3) Trisodium citrate
    4) Trisodium 2-hydroxypropane-1,2,3-tricarboxylate
    5) Molecular Formula: C6-H5-Na3-O7.2H20
    6) CAS 68-04-2 (anhydrous)
    7) CAS 6132-04-3 (dihydrate)
    SODIUM SULFATE (synonym)
    1) Molecular Formula: Na2-O4-S
    2) Salt cake
    3) CAS 7757-82-6
    SODIUM SULFATE, DECAHYDRATE (synonym)
    1) 514
    2) Glauber's Salt
    3) Glaubersalz
    4) Molecular Formula: Na2-O4-S.10H2O
    5) Natrii Sulfas Decahydricus
    6) Natrii Sulphas
    7) Natrium Sulfuricum Crystallisatum
    8) Sodium Sulphate, decathydrate
    9) CAS 7727-73-3
    GENERAL TERMS
    1) DISODIUM SULPHATE
    2) GLAUBER'S SALT
    3) LAXATIVE (SALINE)
    4) SALINE LAXATIVES
    5) SODIUM SULFATE CRYSTALS

Available Forms Sources

    A) FORMS
    1) Saline cathartics are available in numerous proprietary products and include sodium citrate, sodium sulfate (Glauber's salt), and potassium sodium tartrate (Sollmann, 1957).
    2) POTASSIUM BITARTRATE
    a) Evac-Q-Sert: USA
    b) Trade names of combination products containing potassium bitartrate:
    1) Ceo-Two: USA
    2) Potavescent: Australia
    3) POTASSIUM SODIUM TARTRATE
    a) Compound Effervescent Powder (Seidlitz Powder)
    b) Double-Strength Compound Effervescent Powder
    4) SODIUM SULFATE
    a) Sodium sulfate injection (USP)
    b) Liquisulf: Switzerland
    c) Trade names of combination products containing sodium sulfate:
    1) Colyte: Canada, USA
    2) Cuproxil: Australia
    3) GoLytely: USA
    4) Prefagyl: Canada
    5) Recipe for CARLSBAD SALT, ARTIFICIAL:
    Potassium sulfate1 part
    Sodium chloride9 parts
    Sodium bicarbonate18 parts
    Sodium sulfate (anhydrous)22 parts

    6) Recipe for CARLSBAD SALT ARTIFICIAL, EFFERVESCENT:
    Carlsbad Salt Artificial25 parts
    Sodium bicarbonate48 parts
    Tartaric acid17 parts
    Citric acid25 parts

    7)
    Rochelle salt3 parts
    Sodium bicarbonate1 part
    10 grams of this mixture with 2.17 grams tartaric acid for one Seidlitz powder

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Saline laxatives and cathartics are used in the treatment of constipation. This class of laxatives include: citrate, sulfate, and tartrate salts of potassium or sodium.
    B) EPIDEMIOLOGY: Toxicity from overdose is rare. Chronic laxative abuse may occur in patients with eating disorders, Munchausen Syndrome or factitious disorders.
    C) PHARMACOLOGY: Saline cathartics are salts which retain fluids in the intestine by the osmotic action of the unabsorbed salt indirectly producing an increase in peristalsis.
    D) TOXICOLOGY: Saline cathartics are poorly absorbed from the gastrointestinal tract hence, systemic toxicity is unlikely unless massive amounts have been ingested. Large exposures can cause dehydration and electrolyte disturbances secondary to the osmotic effects.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Typically, patients experience nausea, vomiting, and diarrhea associated with abdominal cramping.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: The vast majority of cases are mild and patients experience nausea, vomiting, diarrhea, and abdominal cramping.
    2) SEVERE TOXICITY: Saline cathartics are poorly absorbed from the gastrointestinal tract hence, systemic toxicity is unlikely unless massive amounts have been ingested. Severe effects may include dehydration, hypotension, hypernatremia, and electrolyte abnormalities. Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate).
    3) CARDIOVASCULAR: A laxative withdrawal syndrome is described which is caused by persistent hyperaldosteronism and clinically manifested by edema. Theoretically, absorption of sodium could precipitate heart failure, but this has not been reported.
    4) GASTROINTESTINAL: Nausea, vomiting, and diarrhea associated with abdominal cramping are the most common signs and symptoms of saline toxicity. Patients with atherosclerotic disease receiving cathartics for procedural bowel preparation have been reported to develop ischemic colitis. Small bowel obstruction secondary to medication bezoar has been reported in patients taking laxatives chronically.
    5) GENITOURINARY: A mild diuresis may occur following excessive absorption of saline laxatives.
    6) FLUID BALANCE: Dehydration and hypovolemia may develop secondary to excessive diarrhea.
    7) ELECTROLYTE BALANCE: Hypokalemia may develop secondary to excessive diarrhea.
    0.2.20) REPRODUCTIVE
    A) Potassium citrate is classified as pregnancy category A. The magnesium sulfate, potassium sulfate, and sodium sulfate combination and polyethylene glycol (PEG) 3350 and electrolytes solution are classified as pregnancy category C.
    0.2.21) CARCINOGENICITY
    A) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE: At the time of this review, the manufacturer does not report any carcinogenic potential.

Laboratory Monitoring

    A) Monitor electrolytes especially potassium and sodium closely in the case of massive overdose, severe diarrhea or those symptomatic patients with heart failure.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) In most cases, oral hydration and observation are all that is needed.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Intravenous hydration and correction of electrolyte abnormalities may be necessary.
    C) DECONTAMINATION
    1) Significant systemic absorption does not occur so GI decontamination is not recommended.
    D) AIRWAY MANAGEMENT
    1) Airway management is rare necessary; intubation should be needed as clinically indicated.
    E) ANTIDOTE
    1) No antidote is available.
    F) CONGESTIVE HEART FAILURE
    1) For patients with excessive sodium absorption and normal renal function, hypernatremia and volume overload can be managed with a diuretic such as furosemide (1 mg/kg/IV start with 20 mg in those naive to furosemide).
    G) HYPOTENSION
    1) Infuse isotonic fluids is usually sufficient in most cases. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (DOSE: ADULT: Infuse at 0.5 to 1 mcg/min; CHILD: Infuse at 0.1 mcg/kg/min); titrate to desired response.
    H) HYPOKALEMIA
    1) Monitor potassium if significant GI loss or dehydration. Replace potassium orally or intravenously as needed.
    I) ENHANCED ELIMINATION
    1) Excessive sodium absorbed will be renally eliminated. Enhanced elimination is generally unnecessary except in patients with renal failure and severe hypernatremia or volume overload.
    J) PATIENT DISPOSITION
    1) HOME CRITERIA: Asymptomatic patients or those with mild diarrhea and inadvertent exposure can be managed at home.
    2) ADMISSION CRITERIA: Patients with significant hypernatremia, confusion, dehydration, or hypotension should be admitted, observed, and carefully rehydrated.
    3) OBSERVATION CRITERIA: Patients with deliberate overdose or severe diarrhea should be referred to a healthcare facility for evaluation.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity. Severe toxicity is exceedingly rare.
    K) PHARMACOKINETICS
    1) Not well studied.
    L) DIFFERENTIAL DIAGNOSIS
    1) Dehydration may develop from multiple causes (eg, gastroenteritis).

Range Of Toxicity

    A) TOXICITY: A toxic dose has not been established. Theoretically, a massive ingestion could cause hypernatremia, but the required dose is not known. Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate) which is approximately 3.5 times the daily FDA recommendation of at least 4.7 grams (120 mmoles) of potassium.

Clinical Effects

Summary Of Exposure

    A) USES: Saline laxatives and cathartics are used in the treatment of constipation. This class of laxatives include: citrate, sulfate, and tartrate salts of potassium or sodium.
    B) EPIDEMIOLOGY: Toxicity from overdose is rare. Chronic laxative abuse may occur in patients with eating disorders, Munchausen Syndrome or factitious disorders.
    C) PHARMACOLOGY: Saline cathartics are salts which retain fluids in the intestine by the osmotic action of the unabsorbed salt indirectly producing an increase in peristalsis.
    D) TOXICOLOGY: Saline cathartics are poorly absorbed from the gastrointestinal tract hence, systemic toxicity is unlikely unless massive amounts have been ingested. Large exposures can cause dehydration and electrolyte disturbances secondary to the osmotic effects.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: Typically, patients experience nausea, vomiting, and diarrhea associated with abdominal cramping.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: The vast majority of cases are mild and patients experience nausea, vomiting, diarrhea, and abdominal cramping.
    2) SEVERE TOXICITY: Saline cathartics are poorly absorbed from the gastrointestinal tract hence, systemic toxicity is unlikely unless massive amounts have been ingested. Severe effects may include dehydration, hypotension, hypernatremia, and electrolyte abnormalities. Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate).
    3) CARDIOVASCULAR: A laxative withdrawal syndrome is described which is caused by persistent hyperaldosteronism and clinically manifested by edema. Theoretically, absorption of sodium could precipitate heart failure, but this has not been reported.
    4) GASTROINTESTINAL: Nausea, vomiting, and diarrhea associated with abdominal cramping are the most common signs and symptoms of saline toxicity. Patients with atherosclerotic disease receiving cathartics for procedural bowel preparation have been reported to develop ischemic colitis. Small bowel obstruction secondary to medication bezoar has been reported in patients taking laxatives chronically.
    5) GENITOURINARY: A mild diuresis may occur following excessive absorption of saline laxatives.
    6) FLUID BALANCE: Dehydration and hypovolemia may develop secondary to excessive diarrhea.
    7) ELECTROLYTE BALANCE: Hypokalemia may develop secondary to excessive diarrhea.

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) RIGHT HEART FAILURE
    1) WITH THERAPEUTIC USE
    a) Absorption of sodium from a saline cathartic may aggravate congestive heart failure (Hardman et al, 1996).
    b) Congestive heart failure has been reported after cathartic withdrawal (Riley et al, 1995).
    B) EDEMA
    1) WITH THERAPEUTIC USE
    a) Edema following saline laxative withdrawal is not uncommon (Riley et al, 1996). The presumed mechanism is persistent hyperaldosteronism resulting in sodium retention.
    C) CONDUCTION DISORDER OF THE HEART
    1) WITH POISONING/EXPOSURE
    a) POTASSIUM BITARTRATE
    1) Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate) (Rusyniak et al, 2013).
    a) CASE REPORT: A 16-year-old man presented with nausea and vomiting about 4 hours after ingesting 6 tablespoons of cream of tartar (potassium bitartrate). An ECG revealed a normal sinus rhythm with a heart rate of 79 beats/min, flattened P waves, and peaked T waves. Laboratory results 5 to 6 hours postingestion showed marked hyperkalemia (8.5 mmol/L; reference range: 3.5 to 5.1), a mildly elevated chloride concentration (121 mmol/L; reference range: 95 to 105), and mild acidemia (CO2: 20 mmol/L; reference range: 21 to 32). Following supportive care, including treatment with IV sodium bicarbonate (50 mEq), regular insulin (10 units), calcium gluconate (4.65 mEq), nebulized albuterol, and sodium polystyrene sulfonate (15 g), his potassium concentration (4.4 mmol/L) and ECG normalized within 4 hours of arrival (Rusyniak et al, 2013).
    b) CASE REPORT: A 32-year-old man developed diarrhea and vomiting 4 hours after ingesting about 6 tablespoons of cream of tartar (potassium bitartrate) mixed in water. Muscle weakness and difficulty ambulating developed the next day. He was transported to the local ED about 24 hours postingestion and an ECG revealed a sinus bradycardia (heart rate of 55 beats/min) with peaked T waves. Laboratory results revealed marked hyperkalemia (8.7 mmol/L) and mild renal insufficiency with a BUN of 10.7 mmol/L (reference range: 2.9 to 8.6) and a creatinine of 168 mcmol/L (reference range: 53 to 115). Following supportive care, including treatment with IV sodium bicarbonate (50 mEq), regular insulin (10 units), and calcium chloride (13 mEq), his potassium level decreased to 5.9 mmol/L within 4 hours of presentation and decreased to 5.4 mmol/L by 24 hours. His renal function (BUN: 8.57 mmol/L; serum creatine: 115 mcmol/L) returned to normal the next day (Rusyniak et al, 2013).
    c) It is reported that cream of tartar is 20% potassium. Six tablespoons of cream of tartar from a bottle that contains 28 g/ounce, contains 3 ounces or 84 grams of cream of tartar and 16.8 grams (430 mmoles) of potassium. Based on this information, these patients ingested 3.5 times the daily FDA recommendation of at least 4.7 grams (120 mmoles) of potassium (Rusyniak et al, 2013)

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) Seizures may occur with elevated serum sodium levels.

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea is a common effect of saline laxative overdose (Larson et al, 1986).
    B) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) There may also be abdominal pain and cramping.
    C) DEHYDRATION
    1) Dehydration may occur if fluid loss is extensive (Sotos et al, 1977).
    D) ISCHEMIC COLITIS
    1) CASE REPORT: Two women developed abdominal pain and diarrhea after ingesting hyperosmotic cathartics (magnesium citrate and sodium phosphate). Colonoscopy suggested ischemic colitis (Oh et al, 1997). Similar effects might develop after ingestion of hyperosmotic saline laxatives.
    E) INTESTINAL OBSTRUCTION
    1) Small bowel obstruction secondary to medication bezoar has been reported in patients taking laxatives chronically (Tatekawa et al, 1996).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) POLYURIA
    1) Absorbed saline compounds may act as a mild diuretic (Sollman, 1957). Because of water loss, urine volume may decrease in the first 12 hours and then increase for a day.
    a) Because the diuresis is related to absorbed ions, it is inversely proportional to catharsis (Sollmann, 1957).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) CASE REPORT: An 11-month-old, 8.5 kg infant developed profound acidosis (pH 6.62) following oral administration of 800 mL lavage solution (GoLYTELY which contains mostly polyethylene glycol, and sodium bicarbonate or sodium sulfate) and 4 adult-size sodium phosphate enemas (Martin et al, 1987).

Reproductive

    3.20.1) SUMMARY
    A) Potassium citrate is classified as pregnancy category A. The magnesium sulfate, potassium sulfate, and sodium sulfate combination and polyethylene glycol (PEG) 3350 and electrolytes solution are classified as pregnancy category C.
    3.20.2) TERATOGENICITY
    A) LACK OF INFORMATION
    1) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    a) At the time of this review, no data were available to assess the teratogenic potential of this combination product (Prod Info GoLYTELY oral solution, 2013).
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    a) At the time of this review, no data were available to assess the potential effects of exposure to this combination product during pregnancy in humans (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    2) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    a) At the time of this review, no data were available to assess the potential effects of exposure to this combination product during pregnancy in humans (Prod Info GoLYTELY oral solution, 2013).
    B) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    1) There are no adequate and well-controlled studies of the magnesium sulfate, potassium sulfate, and sodium sulfate combination in pregnant women. Therefore, it is recommended that the drug be administered in pregnant women only if clearly necessary (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    C) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    1) There are no adequate and well-controlled studies of polyethylene glycol (PEG) 3350 and electrolytes oral solution use in pregnant women. Animal studies have not been conducted. It is currently unknown if PEG 3350 and electrolytes oral solution use during pregnancy can result in fetal harm. The effects on reproductive capacity are currently not known. As a result, the manufacturer recommends the use of this combination product during pregnancy only if clearly needed (Prod Info GoLYTELY oral solution, 2013).
    D) PREGNANCY CATEGORY
    1) Potassium citrate is classified as FDA pregnancy category A (Briggs et al, 1998).
    2) The polyethylene glycol 3350 and electrolytes oral solution is classified as FDA pregnancy category C (Prod Info GoLYTELY oral solution, 2013)
    3) The magnesium sulfate, potassium sulfate, and sodium sulfate combination is classified as FDA pregnancy category C (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    a) At the time of this review, no data were available to assess the potential effects of exposure to this combination product during lactation in humans (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    2) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    a) At the time of this review, no data were available to assess the potential effects of exposure to this combination product during lactation in humans (Prod Info GoLYTELY oral solution, 2013).
    B) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    1) It is unknown whether the magnesium sulfate, potassium sulfate, and sodium sulfate combination is excreted in human milk. Because many drugs are excreted in human milk, exercise caution when administering this combination to a woman who is breastfeeding (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    C) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    1) Lactation studies with polyethylene glycol (PEG) 3350 and electrolytes solution have not been conducted. It is unknown whether PEG 3350 and electrolytes oral solution is excreted in human milk. Because many drugs are excreted in human milk, exercise caution when administering this combination to a woman who is breastfeeding (Prod Info GoLYTELY oral solution, 2013).
    3.20.5) FERTILITY
    A) LACK OF INFORMATION
    1) POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES SOLUTION
    a) At the time of this review, no data were available to assess the potential effects on fertility from exposure to this combination product (Prod Info GoLYTELY oral solution, 2013).

Carcinogenicity

    3.21.2) SUMMARY/HUMAN
    A) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE: At the time of this review, the manufacturer does not report any carcinogenic potential.
    3.21.4) ANIMAL STUDIES
    A) LACK OF INFORMATION
    1) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    a) Long-term studies evaluating the carcinogenic potential of this combination in animals have not been performed (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).

Genotoxicity

    A) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE: At the time of this review, the manufacturer does not report any genotoxic or mutagenic effects of this agent (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor electrolytes especially potassium and sodium closely in the case of massive overdose, severe diarrhea or those symptomatic patients with heart failure.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Fluid and electrolyte status should be monitored at regular intervals. Patients demonstrating moderate to severe symptoms should have serum potassium and sodium concentrations monitored.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients with significant hypernatremia, confusion, dehydration, or hypotension should be admitted, observed, and carefully rehydrated.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Asymptomatic patients or those with mild diarrhea and inadvertent exposure can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity. Severe toxicity is exceedingly rare.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with deliberate overdose or severe diarrhea should be referred to a healthcare facility for evaluation.

Monitoring

    A) Monitor electrolytes especially potassium and sodium closely in the case of massive overdose, severe diarrhea or those symptomatic patients with heart failure.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Significant systemic absorption does not occur so GI decontamination is not recommended.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Significant systemic absorption does not occur so GI decontamination is not recommended.
    B) ACTIVATED CHARCOAL
    1) LACK OF EFFICACY: Due to molecular size and ionic dissociation, charcoal is NOT likely to be beneficial (Arena & Drew, 1986).
    6.5.3) TREATMENT
    A) SUPPORT
    1) In most cases, oral hydration and observation are all that is needed. Intravenous hydration and correction of electrolyte abnormalities may be necessary in some individuals.
    2) Monitor electrolytes especially potassium and sodium closely in the case of massive overdose, severe diarrhea or those symptomatic patients with heart failure.
    B) DIARRHEA
    1) TREATMENT: Restrict solid food and maintain high fluid intake until diarrhea resolves. Oral fluids should consist of hypotonic solution containing appropriate electrolytes such as oral Pedialyte(R) or Gatorade(R).
    C) FLUID/ELECTROLYTE BALANCE REGULATION
    1) Intravenous hydration and correction of electrolyte abnormalities may be necessary. Coma, lethargy, or CNS depression may be a result of severe dehydration and will respond to fluid replacement.
    D) CONGESTIVE HEART FAILURE
    1) Patients developing congestive heart failure from sodium intoxication may be treated with fluid restriction and/or diuretic therapy, furosemide 1 mg/kg/IV to a maximum of 40 mg.
    E) HYPOTENSIVE EPISODE
    1) SUMMARY
    a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.
    2) DOPAMINE
    a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    3) NOREPINEPHRINE
    a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
    b) DOSE
    1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
    2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
    3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).

Enhanced Elimination

    A) SUMMARY
    1) Generally, excessive sodium absorption will be renally eliminated. Enhanced elimination is generally unnecessary except in patients with renal failure and severe hypernatremia or volume overload.

Range Of Toxicity

Summary

    A) TOXICITY: A toxic dose has not been established. Theoretically, a massive ingestion could cause hypernatremia, but the required dose is not known. Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate) which is approximately 3.5 times the daily FDA recommendation of at least 4.7 grams (120 mmoles) of potassium.

Therapeutic Dose

    7.2.1) ADULT
    A) SPECIFIC SUBSTANCE
    1) POTASSIUM BITARTRATE - A dose of 1 gram has been used as a laxative (JEF Reynolds , 1996).
    2) POTASSIUM SODIUM TARTRATE - Doses of 8 to 16 grams have been used as a laxative (Sweetman, 2002).
    3) SODIUM CITRATE
    a) CYSTITIS - Up to 10 grams of sodium citrate dihydrate (102 millimoles sodium, 34 millimoles citrate) may be administered daily in divided doses, well diluted and after meals (JEF Reynolds , 1996).
    b) CONSTIPATION - Solutions containing 450 milligrams of sodium citrate dihydrate (153 millimoles sodium, 51 millimoles citrate) administered as rectal enema (JEF Reynolds , 1996).
    4) SODIUM SULFATE, DECAHYDRATE
    a) Administered by mouth as dilute solution as a laxative (JEF Reynolds , 1996).
    b) Intravenous administration of 3.89 percent solution by slow infusion has been used in the treatment of severe hypercalcemia (JEF Reynolds , 1996).
    5) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    a) CLEANSING THE COLON AS PREPARATION FOR COLONOSCOPY: using a split-dose regimen, one 6-ounce bottle (containing 1.6 g magnesium sulfate, 3.13 g potassium sulfate, 17.5 g sodium sulfate), diluted with water in a mixing container, up to 16-ounce fill line, is administered orally during evening before colonoscopy followed 10 to 12 hours later by another 6-ounce bottle (diluted with water) orally the next day (morning of colonoscopy) (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).
    7.2.2) PEDIATRIC
    A) SPECIFIC SUBSTANCE
    1) SODIUM CITRATE
    a) 1 to 14 years of age - 0.4 milliliter/kilogram of 0.3 molar solution of sodium citrate was administered preoperatively to raise the pH of gastric contents (Henderson et al, 1987).
    2) MAGNESIUM SULFATE/POTASSIUM SULFATE/SODIUM SULFATE
    a) Safety and efficacy in the pediatric population have not been established (Prod Info SUPREP Bowel Prep Kit oral solution, 2012).

Maximum Tolerated Exposure

    A) POTASSIUM BITARTRATE
    1) Hyperkalemia and ECG abnormalities developed in 2 patients after ingesting 6 tablespoons of cream of tartar (potassium bitartrate). It is reported that cream of tartar is 20% potassium. Six tablespoons of cream of tartar from a bottle that contains 28 g/ounce, contains 3 ounces or 84 grams of cream of tartar and 16.8 grams (430 mmoles) of potassium. Based on this information, these patients ingested 3.5 times the daily FDA recommendation of at least 4.7 grams (120 mmoles) of potassium (Rusyniak et al, 2013).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Saline cathartics are salts which retain fluids in the intestine by the osmotic action of the unabsorbed salt indirectly producing an increase in peristalsis (Sollmann, 1957).

Physicochemical

Physical Characteristics

    A) POTASSIUM BITARTRATE: Colorless to white, nearly odorless crystals or crystalline powder (Sweetman, 2002).
    B) POTASSIUM SODIUM TARTRATE: Colorless or white, nearly odorless crystals or crystalline powder with a cooling saline taste (Sweetman, 2002)
    C) SODIUM CITRATE: White odorless crystalline powder or granular crystals (Sweetman, 2002).
    D) SODIUM SULFATE: Transparent or white, nearly odorless, large crystals or crystalline powder (Sweetman, 2002).

Molecular Weight

    A) POTASSIUM BITARTRATE: 188.2 (Sweetman, 2002)
    B) POTASSIUM SODIUM TARTRATE: 282.2 (Sweetman, 2002)
    C) SODIUM CITRATE
    1) Anhydrous: 258.09 (JEF Reynolds , 1996)
    2) Dihydrate: 294.13 (JEF Reynolds , 1996)
    D) SODIUM SULFATE: 322.2 (Sweetman, 2002)

References

General Bibliography

    1) Arena J & Drew RH: Poisoning, 5th ed, Charles C Thomas Publishing, Springfield, IL, 1986.
    2) Briggs GG, Freeman RK, & Yaffe SJ: Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 5th ed, Williams & Wilkins, Baltimore, MD, 1998.
    3) Hardman JG, Limbird LE, & Molinoff PB: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 9th ed, McGraw-Hill, New York, NY, 1996.
    4) Henderson JM, Spence DG, & Clarke WN: Sodium citrate in paediatric outpatients. Can J Anaesth 1987; 6:560-562.
    5) JEF Reynolds : Martindale: The Extra Pharmacopoeia, 31st ed. The Pharmaceutical Press. London, UK (Internet Version). Edition expires 1996; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    6) Kleinman ME, Chameides L, Schexnayder SM, et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 14: pediatric advanced life support. Circulation 2010; 122(18 Suppl.3):S876-S908.
    7) Larson JE, Swigart SA, & Angle CR: Laxative phosphate poisoning: pharmacokinetics of serum phosphorus. Hum Toxicol 1986; 5(1):45-49.
    8) Martin RR, Lisehora GR, & Braxton M Jr: Fatal poisoning from sodium phosphate enema. JAMA 1987; 257:2190-2192.
    9) Oh JK, Meiselman M, & Lataif LE Jr: Ischemic colitis caused by oral hyperosmotic saline laxatives. Gastrointestinal Endoscopy 1997; 45:319-322.
    10) Peberdy MA , Callaway CW , Neumar RW , et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 9: post–cardiac arrest care. Circulation 2010; 122(18 Suppl 3):S768-S786.
    11) Product Information: GoLYTELY oral solution, polyethylene glycol 3350 electrolytes oral solution. Braintree Laboratories, Inc. (per FDA), Braintree, MA, 2013.
    12) Product Information: SUPREP Bowel Prep Kit oral solution, sodium sulfate potassium sulfate magnesium sulfate oral solution. Braintree Laboratories, Inc. (per FDA), Braintree, MA, 2012.
    13) Product Information: dopamine hcl, 5% dextrose IV injection, dopamine hcl, 5% dextrose IV injection. Hospira,Inc, Lake Forest, IL, 2004.
    14) Product Information: norepinephrine bitartrate injection, norepinephrine bitartrate injection. Sicor Pharmaceuticals,Inc, Irvine, CA, 2005.
    15) Riley JA, Brown AR, & Walker BE: Congestive cardiac failure following laxative withdrawal. Postgrad Med J 1996; 72:491-492.
    16) Rusyniak DE, Durant PJ, Mowry JB, et al: Life-threatening hyperkalemia from cream of tartar ingestion. J Med Toxicol 2013; 9(1):79-81.
    17) S Sweetman : Martindale: The Complete Drug Reference. Pharmaceutical Press. London, UK (Internet Version). Edition expires 2002; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    18) Sollmann T: A Manual of Pharmacology, 8th ed, WB Saunders Co, Philadelphia, PA, 1957.
    19) Sotos JF, Cutler EA, & Finkel DO: Hypocalcemic coma following two pediatric phosphate enemas. Pediatrics 1977; 60:305-307.