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IPECAC

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Ipecac is an emetic that exerts its effect by prompting gastric irritation and through a central effect by stimulating the chemoreceptor trigger zone. It is no longer routinely recommended for use in the management of acute poisoning.

Specific Substances

    1) Amebicide
    2) Emetine, dihydrochloride
    3) (-)-emetine dihydrochloride
    4) l-emetine dihydrochloride
    5) Emetine, hydrochloride
    6) Emetini chloridum
    7) Emetini hydrochloridum
    8) Ipecacuanha
    9) Ipecacuanha root
    10) Ipecacuanhae radix
    11) Ipecine hydrochloride
    12) Methylcephaeline hydrochloride
    1.2.1) MOLECULAR FORMULA
    1) C29-H40-N2-O4.2Cl-H

Available Forms Sources

    A) FORMS
    1) ACTIVE INGREDIENTS
    a) BOTTLE CONTENTS: Syrup of ipecac contains 70 mg of powdered ipecac per mL. A 30 mL bottle of ipecac syrup contains approximately 24 mg of emetine and 31 mg of cephaeline (Anon, 1997). It also contains glycerin 10% and alcohol 1 to 2.5%.
    b) Since 1975, only the syrup form formulated from the raw material is available for commercial use. In previous years, a fluid extract form had served as the basis for the syrup; it was 14 times as concentrated and on several occasions was inadvertently substituted for the syrup form that led to fatalities. The fluid extract form has been discontinued.
    B) SOURCES
    1) AVAILABILITY
    a) As May 2010, Ipecac syrup, 30 mL (NDC 00395-1237-91) by Humco has been discontinued. In addition, Paddock laboratories has placed their ipecac syrup (30 mL bottle [NDC 00574-0012-01]) on long-term back order due to a global shortage of raw material to manufacturer the product. An estimated date for product availability could not be determined by the company (American Society of Health-System Pharmacists, 2010).
    b) Despite its limited use in the treatment of poisoning, ipecac remains a potential product for abuse and misuse. A survey was conducted in the late 1990s in California and syrup of ipecac was still widely available for purchase in many pharmacies (both chain and locally owned stores). In another survey conducted in an urban area in both 2003 and 2005, the availability of the syrup of ipecac at local pharmacies had declined significantly. However, it was still available in more than 50% of pharmacies and was usually available on a store shelf (Nordt et al, 1999; Kelly & Sanchez, 2007).
    2) STABILITY
    a) SUMMARY: Ipecac syrup is labeled with an expiration date derived from data submitted by the manufacturer. No significant difference in emetic response has been noted to outdated ipecac (Hornfeldt & Rogers, 1984) or ipecac stored up to five years at home (Mowry et al, 1981; Grbcich et al, 1986) despite anecdotal reports (Huff et al, 1984) of delayed emetic action of outdated ipecac.
    b) STUDIES
    1) A loss of potency in 5 of 15 samples of outdated syrup of ipecac (7 to 72 months), significant enough to fall below USP standards, has been observed. Six of 15 failed USP standards on the basis of the emetine/cephaeline ratio. However, there was no significant difference between the time for emesis to occur with the outdated and control "in date" syrup of ipecac (Hornfeldt & Rogers, 1984).
    c) DEGRADATION PRODUCTS: It is unknown whether harmful degradation products are produced in outdated ipecac syrup, and thus, "in date" preparations should be used when possible.
    C) USES
    1) GENERAL GUIDELINES: EMETIC
    a) Ipecac syrup, administered orally, is an emetic that may minimize the absorption of drugs or toxins that have been swallowed. According to the 1997 AAPCC position statement, ipecac should not be routinely administered in the management of poisoned patients (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004; Anon, 1997). There is minimal evidence that the use of ipecac improves patient outcome (Manoguerra & Cobaugh, 2005; Garrettson, 1991). Other methods of gastrointestinal decontamination are preferred for use in medical care settings.
    b) Ipecac should only be considered for the treatment of a patient in whom (Manoguerra & Cobaugh, 2005):
    1) There is no contraindication.
    2) There is a substantial chance of serious toxicity based on the substance quantity ingested.
    3) There is no apparent alternative available to decrease GI absorption.
    4) There will be a delay of more than 1 hour before a patient can reach an emergency medical facility.
    5) Ipecac can be administered within 30 to 90 minutes of ingestion.
    c) The use of ipecac has been decreasing over the past few decades. The use of ipecac syrup in hospitals peaked in 1985, and has declined substantially since that time. The American Association of Poison Control Centers Toxic Exposure Surveillance System found that ipecac syrup was used in 0.7% of exposures in 2001 as compared to 15% in 1985 (Manoguerra & Cobaugh, 2005). In 1999, US poison centers recommended ipecac in 1.0% of cases (Litovitz et al, 2000).
    1) In a review of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a review of Emergency Department admissions that included the code of ipecac from 1992 through 2002, a total of 93 visits mention the use of ipecac. An overall steady decline in ipecac use was observed during the study period. In 1998 through 2002, as few as 3 (0.01%) visits reported the use of ipecac (Brinker & Nourjah, 2006).
    2) In a review of data from 2000 and 2001 of each of the 64 poison centers in the US of cases involving children less than 6 years of age who unintentionally ingested a pharmaceutical agent who were being cared for initially in the home, the mean use of ipecac in the home was 1.8% (range: 0.2% to 14%); adverse events were rare (0.6% [range: 0.2% to 2.1%]. The findings suggested that there was no difference in referral rate or improvement in patient outcome with the use of ipecac in the home (Bond, 2003).
    d) AMERICAN ACADEMY OF PEDIATRICS RECOMMENDATION
    1) PREHOSPITAL: The use of syrup of ipecac is NO longer routinely recommended in the home by the American Academy of Pediatrics (AAP). If a child has a potentially poisonous ingestion a Poison Control Center should be contacted immediately for consultation and guidance (Anon, 2003; Meadows-Oliver, 2004). It was recommended in June 2003, that ipecac have its status as an over-the-counter product be rescinded and make it available by prescription only (Shannon, 2003).
    2) The AAP further suggests that parents or caregivers should safely dispose of ipecac found in the home (Anon, 2003).
    2) EFFICACY
    a) A single dose of ipecac syrup produces vomiting in 80% to 85% of patients; and additional 10% to 15% vomit after a second dose; 4% to 5% fail to respond after a second dose (Manoguerra & Cobaugh, 2005).
    b) There are no published reports to support that ipecac-induced emesis has a positive benefit on the outcome of poisoned patients (prehospital or hospital setting) (Krenzelok, 2005; Manoguerra & Cobaugh, 2005). Several studies (involving volunteers and patients) have shown that ipecac administration soon after ingestion reduces serum drug levels (Bond et al, 1993; McNamara et al, 1989; Danel et al, 1988; Tenenbein et al, 1987; Neuvonen & Olkkola, 1984; Neuvonen et al, 1983). However, its usefulness in preventing toxicity (or altering the clinical course of poisoning) has been questioned (Vale et al, 1986; Kulig et al, 1985).
    3) GASTRIC RECOVERY
    a) Average gastric recovery following ipecac-induced emesis was reported to be 28% (Corby et al, 1968). Recovery of unabsorbed LIQUID drug (Thiamine) was 50% +/- 35% following induced emesis compared to 90% +/- 34% with gastric lavage in one study (Auerbach et al, 1986).
    b) In studies with normal volunteers, ipecac has reduced mean (+/-SD) urinary recovery of salicylate from the control value of 96.3 +/- 7.5% to 70.2 +/- 12% (Curtis et al, 1984).
    c) The bioavailability of concomitantly ingested acetaminophen, aminophylline, and tetracycline were significantly reduced by ipecac syrup given 5 or 30 minutes after drug administration except when ipecac was given 30 minutes after aminophylline (Neuvonen et al, 1983).
    d) Ipecac has been reported to reduce the absorption of cimetidine and pindolol in volunteers by 75% and 60%, respectively (Neuvonen & Olkkola, 1984).
    4) INTENTIONAL MISUSE
    a) Intentional misuse of syrup of ipecac has been recognized among some individuals with eating disorders (Pope et al, 1986; Dawson & Yager, 1986). In a study of outpatients (n=851) with eating disorders, the overall incidence (7.6%) of ipecac abuse was relatively small. However, these patients were more likely to have been hospitalized and more likely to have abused other substances for purging (Greenfeld et al, 1993). Fatalities have been reported after chronic use (Dawson & Yager, 1986).
    b) Ipecac has also been used to poison children known as "factitious disorder by proxy" or Munchausen Syndrome by Proxy by parents or caregivers (Cooper et al, 1998; Carter et al, 2006).

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: Syrup of ipecac is used as an emetic. It has been used to induce vomiting following acute poisoning; however, because of its limited benefit to alter patient outcome and potential for harm, the American Academy of Poison Centers no longer recommends its routine use. It has also been intentionally misused among individuals with eating disorders.
    B) PHARMACOLOGY: Syrup of ipecac contains 2 primary alkaloids, cephaeline and emetine (methylcephaeline). Ipecac can induce emesis by prompting gastric irritation and centrally by stimulating the chemoreceptor trigger zone in the brainstem.
    C) TOXICOLOGY: Prolonged retching and vomiting may occur with therapeutic use. Chronic exposure to emetine can produce myopathy affecting both skeletal and cardiac muscles.
    D) EPIDEMIOLOGY: Use in the treatment of poisoning has been rapidly declining. Acute overdose is rare. Chronic misuse occurs in a small percentage of patients with bulimia with rare fatalities.
    E) WITH THERAPEUTIC USE
    1) COMMON: As anticipated, ingestion of syrup of ipecac usually results in vomiting within 15 to 30 minutes. Acute ingestions of therapeutic amounts have produced protracted emesis and potentially serious adverse events, but these are rare. Prolonged vomiting and lethargy have been reported in children following therapeutic doses.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Prolonged retching and vomiting, abdominal cramping, Mallory-Weiss tears, and mild tremor can develop.
    2) SEVERE TOXICITY: Severe vomiting, dehydration, hypotonia, muscle weakness, skeletal muscle myopathy, diarrhea, cardiomyopathy, tachycardia, prolonged QT interval, and dysrhythmias have developed following chronic misuse. Regular abuse of ipecac syrup by patients with major eating disorders have resulted in myopathies of the skeletal and cardiac muscles. Deaths have been reported from emetine-induced cardiomyopathy secondary to chronic misuse.
    3) Chronic deliberate intoxication of ipecac has also been reported rarely in children, generally as a form of Munchausen Syndrome by proxy.

Laboratory Monitoring

    A) Qualitative emetine analysis has been of value for the diagnosis of cases of chronic ingestion of ipecac. However, these levels are not readily available and cannot be used to guide therapy.
    B) Monitor fluid and electrolyte balance if protracted emesis occurs. Monitor CK in patients with evidence of myopathy (weakness or muscle pain).
    C) Obtain an ECG in patients with evidence of chronic poisoning. An echocardiogram may also be indicated in patients with evidence of cardiomyopathy.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Assess bowel function following overdose; monitor for abdominal pain, cramping or distension; prolonged vomiting; diarrhea; or evidence of bowel obstruction. Monitor fluid and electrolyte balance; replaced fluids as indicated. Chronic exposure to emetine can produce cardiomyopathy. Conduction disturbances may develop in patients following chronic exposure. Continuous cardiac monitoring and a baseline ECG and administration of oxygen may be indicated. Lidocaine and amiodarone are generally first line agents for stable monomorphic ventricular tachycardia, particularly in patients with underlying impaired cardiac function. Unstable rhythms require immediate cardioversion.
    C) DECONTAMINATION
    1) PREHOSPITAL: Decontamination is not indicated.
    2) HOSPITAL: Decontamination is not indicated.
    D) ANTIDOTE
    1) None.
    E) AIRWAY MANAGEMENT
    1) Endotracheal intubation and mechanical ventilation may be required in patients with aspiration pneumonitis.
    F) FLUID REPLACEMENT
    1) Monitor fluid status and electrolyte balance. Diarrhea and prolonged vomiting may develop. Replace fluids and electrolytes as indicated.
    G) HYPOTENSION
    1) Fluid replacement is likely to be sufficient to treat hypotension. Administer 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine or norepinephrine. Vasopressors and dobutamine may be necessary in patients with hypotension secondary to cardiomyopathy.
    H) PHARMACOKINETICS
    1) In healthy volunteers, peak plasma concentration occurred in approximately 20 minutes. Average time to onset of emesis occurs within 20 minutes, with most individuals developing emesis within 30 minutes. Individual variation may affect absorption. Very little of the alkaloids are eliminated in the urine, suggesting that emetine and cephaeline are widely distributed in the body and eliminated slowly from the plasma.
    I) PITFALLS
    1) Alteration in bowel function and fluid balance may occur following ipecac, monitor the patient closely. A patient should only be discharged when bowel assessment is normal and patient is able to tolerate fluids, and vital signs are stable.
    J) DIFFERENTIAL DIAGNOSIS
    1) Includes other agents that may cause vomiting, bowel obstruction (eg, cholestyramine) or aspiration pneumonitis (eg, hydrocarbon).
    K) PATIENT DISPOSITION
    1) HOME CRITERIA: A minor exposure (30 mL or less) can likely be managed at home. Persistent vomiting may require assessment in a healthcare facility especially in young children or in individuals that are debilitated or the elderly.
    2) OBSERVATION CRITERIA: Symptomatic patients and those with self harm ingestions should be sent to a healthcare facility for evaluation and treatment as necessary.
    3) ADMISSION CRITERIA: Symptomatic patients (eg, aspiration pneumonia, intestinal obstruction, cardiomyopathy) should be admitted.
    4) CONSULT CRITERIA: Consult a specialist for assistance in managing patients with evidence of aspiration pneumonia, dysrhythmias or bowel obstruction or in whom the diagnosis is unclear.

Range Of Toxicity

    A) TOXICITY: As much as 105 mL of the syrup of ipecac has been retained by one child with only minor ECG changes. Some adults have repeatedly ingested 30 to 60 mL of the syrup and have not developed any acute toxicity other than vomiting. Acute ingestion of as little as 10 mL of the fluid extract (no longer commercially available) form has been associated with fatalities. CHRONIC: Ingestion of 12 mL 3 to 4 times/week resulted in reversible myopathy in one patient. Fatalities have been reported following chronic use of up to 60 mL/day or more for weeks to months. Emetine-related deaths in adults usually occurs with ingestions of greater than 1.25 g total; however most of these patients have severe underlying pathology related to an eating disorder.
    B) THERAPEUTIC DOSE: ADULTS AND ADOLESCENTS: 15 to 30 mL followed immediately by 240 mL of water; may repeat dose in 20 to 30 minutes if emesis does not occur. PEDIATRIC: CHILDREN 1 TO 12 YEARS OF AGE: 15 mL of ipecac syrup, preceded or followed by 4 to 8 ounces (120 to 240 mL) of water. CHILDREN 6 TO 12 MONTHS OF AGE: 5 to 10 mL of ipecac syrup preceded or followed by 4 to 8 ounces (120 to 240 mL) of water. CHILDREN UP TO 6 MONTHS OF AGE: Ipecac should only be administered under the supervision of a physician.

Clinical Effects

Summary Of Exposure

    A) USES: Syrup of ipecac is used as an emetic. It has been used to induce vomiting following acute poisoning; however, because of its limited benefit to alter patient outcome and potential for harm, the American Academy of Poison Centers no longer recommends its routine use. It has also been intentionally misused among individuals with eating disorders.
    B) PHARMACOLOGY: Syrup of ipecac contains 2 primary alkaloids, cephaeline and emetine (methylcephaeline). Ipecac can induce emesis by prompting gastric irritation and centrally by stimulating the chemoreceptor trigger zone in the brainstem.
    C) TOXICOLOGY: Prolonged retching and vomiting may occur with therapeutic use. Chronic exposure to emetine can produce myopathy affecting both skeletal and cardiac muscles.
    D) EPIDEMIOLOGY: Use in the treatment of poisoning has been rapidly declining. Acute overdose is rare. Chronic misuse occurs in a small percentage of patients with bulimia with rare fatalities.
    E) WITH THERAPEUTIC USE
    1) COMMON: As anticipated, ingestion of syrup of ipecac usually results in vomiting within 15 to 30 minutes. Acute ingestions of therapeutic amounts have produced protracted emesis and potentially serious adverse events, but these are rare. Prolonged vomiting and lethargy have been reported in children following therapeutic doses.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Prolonged retching and vomiting, abdominal cramping, Mallory-Weiss tears, and mild tremor can develop.
    2) SEVERE TOXICITY: Severe vomiting, dehydration, hypotonia, muscle weakness, skeletal muscle myopathy, diarrhea, cardiomyopathy, tachycardia, prolonged QT interval, and dysrhythmias have developed following chronic misuse. Regular abuse of ipecac syrup by patients with major eating disorders have resulted in myopathies of the skeletal and cardiac muscles. Deaths have been reported from emetine-induced cardiomyopathy secondary to chronic misuse.
    3) Chronic deliberate intoxication of ipecac has also been reported rarely in children, generally as a form of Munchausen Syndrome by proxy.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Occupational exposure to ipecac dust causes little immediate discomfort, but is followed in 30 to 60 minutes by tearing, photophobia, blurred vision, conjunctival injection, miosis and roughness of the corneal epithelium which heals spontaneously within a few days (Grant & Schuman, 1993).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) CONDUCTION DISORDER OF THE HEART
    1) WITH THERAPEUTIC USE
    a) In adults, therapeutic doses of syrup of ipecac do not cause cardiac dysrhythmias (Meester, 1980).
    2) WITH POISONING/EXPOSURE
    a) CHRONIC EXPOSURE: Emetine, the major constituent in syrup of ipecac, has produced dysrhythmias, and death in patients ingesting overdoses of fluid extract of ipecac (no longer available) and in patients ingesting high doses of syrup of ipecac for prolonged periods of time (Combs & Acosta, 1990; Manno & Manno, 1977; Adler et al, 1980; Kunkel, 1985; Andersen et al, 1997). The damage to the heart appears cumulative (Combs & Acosta, 1990).
    b) ECG abnormalities have included tachycardia, depression and inversion of T-waves, alteration in QRS complex, prolonged PR interval and QTc, ST-segment abnormalities, atrial tachycardia, premature atrial beats, ventricular tachycardia, and ventricular fibrillation (Kuntzer et al, 1989; Manno & Manno, 1977; Kunkel, 1985; Carraccio et al, 1993; Andersen et al, 1997; Ho et al, 1998; Schneider et al, 1996; Vanin, 1992). Emetine-induced cardiac arrest caused by asystole or ventricular fibrillation is usually preceded by atrial tachycardia and premature beats (Palmer & Guay, 1985).
    c) CASE REPORT: One case report described the need for a cardiac pacemaker in a 23-month-old who was administered 90 mL of syrup of ipecac to treat a large phenothiazine overdose (MacLeod, 1963). The role of the phenothiazine in producing the cardiac toxicity could not be excluded.
    B) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypotension may occur if profuse vomiting or diarrhea results or secondary to cardiac toxicity from chronic ipecac abuse (Schneider et al, 1996; Ho et al, 1998; Vanin, 1992).
    C) CARDIOMYOPATHY
    1) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) There have been a number of cases reported involving chronic ipecac use in patients with eating disorders and children with Munchausen's syndrome by proxy, where ipecac has been associated with cardiomyopathies.
    a) Typical findings include ECG changes such as prolonged QTc interval, T-wave flattening or inversion, and tachycardia (Ho et al, 1998; Schneider et al, 1996). Echocardiography may reveal ventricular dysfunction, reduced ejection fraction and fractional shortening (Ho et al, 1998; Schneider et al, 1996; Andersen et al, 1997).
    b) PATHOLOGY: Emetine appears to produce a direct toxic effect on the heart by decreasing the metabolic activity in the heart muscle fibers and loss of contractility. Cardiomyopathy can improve with discontinued use (Vanin, 1992).
    c) Electron microscopy of the myocardium may reveal zones of myofibrillar lysis, fragmented fibers, irregular alignment or clumps of Z-bands (Schneider et al, 1996; Andersen et al, 1997).
    b) CASE REPORTS
    1) PEDIATRIC: A 9-year-old boy who was chronically poisoned with ipecac developed persistent tachycardia, severe congestive heart failure, cardiomyopathy, cardiomegaly and progressive weakness. Although the parent denied ipecac use, serum markers were positive for ipecac (emetine levels were 19.5 ng/mL (serum) and 76 ng/mL (urine)). Cardiac function improved with supportive care, and no further symptoms were reported once the child was removed from the living environment (Carter et al, 2006; Wagner & Bowers, 2006).
    2) PEDIATRIC: A 16-month-old boy had laboratory evidence of skeletal and cardiac myopathy resulting from intentional poisoning with ipecac by his mother (Sutphen & Saulsbury, 1988).
    3) PEDIATRIC: An enlarged heart (dilation of all 4 chambers) and tricuspid and mitral valve insufficiency were seen in a 4-year-old given an unknown amount of ipecac over a week. The child died with a serum emetine level of 0.5 mg/L (Day et al, 1989).
    4) ADULT: Cardiomyopathy resulting in decreased cardiac ejection fraction of 40% has been described in a 19-year-old bulimic patient who chronically abused ipecac (Friedman et al, 1987).
    5) ADULT: Emetine-induced myopathy with ECG changes resolved in a 21-year-old woman after she discontinued use of ipecac for weight control (Kuntzer et al, 1989).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) Occupational asthma has been reported in workers handling and packing ipecacuanha tablets (Seaton, 1990; Luczynska et al, 1984).
    B) ASPIRATION PNEUMONIA
    1) WITH THERAPEUTIC USE
    a) Because of the risk of aspiration, syrup of ipecac is not recommended in patients without an intact gag reflex (Sacchetti et al, 1987) or who are expected to deteriorate in the next 60 minutes.
    C) MEDIASTINAL EMPHYSEMA
    1) WITH THERAPEUTIC USE
    a) PNEUMOMEDIASTINUM and pneumoretroperitoneum have been reported as an unusual complication of syrup of ipecac induced emesis in one case (Wolowodiuk et al, 1984).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) DROWSY
    1) WITH THERAPEUTIC USE
    a) Drowsiness is a common adverse event associated with ipecac use (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    b) Lethargy was reported in 11.6% of 146 patients and 2.9% of 762 patients following ipecac syrup induced emesis (Czajka & Russell, 1985; Veltri & Temple, 1976).
    B) INTRACRANIAL HEMORRHAGE
    1) WITH THERAPEUTIC USE
    a) A case of an INTRACEREBRAL BLEED in an 84-year-old woman which resulted in death has been reported. This bleed was temporally related to the administration of syrup of ipecac which induced 7 episodes of vomiting over 3 hours (Klein-Schwartz et al, 1984).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) VOMITING
    1) WITH THERAPEUTIC USE
    a) Vomiting generally occurs within 15 to 30 minutes following ingestion of a therapeutic dose (Manoguerra & Krenzelok, 1978). Prolonged (greater than one hour) vomiting is a common adverse event associated with therapeutic ipecac use (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    b) Protracted vomiting, abdominal cramps, and profuse diarrhea may be expected with large doses of syrup of ipecac and in some patients sensitive to the effects of ipecac.
    c) PROLONGED VOMITING
    1) Prolonged vomiting has been reported in 17.1% of 146 patients, and in 9.4% of 762 patients receiving syrup of ipecac (Czajka & Russell, 1985; Veltri & Temple, 1976).
    2) Prolonged vomiting was reported in 8% of children receiving 15 mL and 10.3% receiving 30 mL (Lipscomb et al, 1986). The incidence of prolonged vomiting was not significantly different in a study of 460 children aged 1 to 5 years who received 15 mL or 30 mL; but 3 patients in the 30 mL group vomited for more than 4.5 hours (Smolinske et al, 1987).
    3) Uncommon adverse effects that have been reported secondary to prolonged emesis include Mallory-Weiss tear at the cardioesophageal junction, other esophageal tears, pneumomediastinum, diaphragmatic rupture, and an intracerebral bleed (Tanberg et al, 1981; Timberlake, 1984; Wolowodiuk et al, 1984; Klein-Schwartz et al, 1984; Robertson, 1984).
    2) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) Protracted vomiting, abdominal cramps, and profuse diarrhea have been reported following overdosage of fluid extract of ipecac (Manno & Manno, 1977).
    2) The same symptoms might be expected with large doses of syrup of ipecac and in some patients sensitive to the effects of ipecac.
    B) PERFORATION OF INTESTINE
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: Gastric rupture and death have been reported in a 2.5-year-old child who received 15 mL of syrup of ipecac to treat an ingestion of one to five chlorpheniramine tablets (Knight & Doucet, 1987).
    b) CASE REPORT: A fatality has been reported following ingestion of syrup of ipecac in a 14-month-old child where vomiting may have caused extrusion of the stomach through a congenital diaphragmatic hernia into the left pleural space resulting in a cardiopulmonary arrest (Robertson, 1979).
    c) PNEUMOMEDIASTINUM and pneumoretroperitoneum have been reported as an unusual complication of syrup of ipecac induced emesis in one case (Wolowodiuk et al, 1984).
    C) ESOPHAGITIS
    1) WITH THERAPEUTIC USE
    a) MALLORY-WEISS ESOPHAGEAL TEAR has been reported in adult patients receiving therapeutic doses of ipecac (Tardberg et al, 1981)(Timberlake, 1984).
    2) WITH POISONING/EXPOSURE
    a) Esophageal and bowel inflammation can occur from chronic misuse of ipecac due to local irritation and increased peristalsis (Vanin, 1992).
    D) INTESTINAL OBSTRUCTION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Intestinal pseudo-obstruction was seen in an 18-year-old given chronic ipecac (amount unknown) by his mother. Emetine levels in the urine were 30 ng/mL, in the stool 130 ng/mL. Discontinuation of the ipecac resulted in full recovery (Santangelo et al, 1989).
    E) COLITIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Hemorrhagic colitis and pseudomelanosis with bloody diarrhea was noted in a 23-month-old chronically given ipecac by his mother (Johnson et al, 1991).
    F) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Diarrhea is one of the most common adverse events associated with ipecac use (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    2) WITH POISONING/EXPOSURE
    a) Diarrhea may be a prominent effect in children receiving ipecac chronically in Munchausen's syndrome by proxy (Schneider et al, 1996; Vanin, 1992). In one child who ultimately died of ipecac-induced cardiomyopathy, extensive evaluation revealed a secretory diarrhea (Andersen et al, 1997).
    b) INCIDENCE: Diarrhea has been reported in 1.4% (Veltri & Temple, 1976) and 13% (Czajka & Russell, 1985) of patients receiving syrup of ipecac. The incidence of diarrhea was significantly higher in children aged 1 to 5 years who received a 30 mL dose (15.5%) versus a 15 mL dose (4.3%) (Smolinske et al, 1987).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) LARGE LIVER
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Hepatomegaly and elevated liver enzymes were reported in a 15-month-old infant after ingesting an unknown amount of ipecac over a period of a few days (Carraccio et al, 1993).
    B) LIVER ENZYMES ABNORMAL
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Elevated liver enzymes were reported in a 14-year-old boy that intentionally abused ipecac (Rashid, 2006).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) TOXIC MYOPATHY
    1) WITH POISONING/EXPOSURE
    a) Several cases of syrup of ipecac induced myopathy resulting in extreme weakness myalgias, muscle stiffness, edema and abnormal muscle structure have been reported (Rashid, 2006; Carter et al, 2006; Wagner & Bowers, 2006; Mateer et al, 1985; Brotman et al, 1981; Bennett et al, 1982; Friedman et al, 1987; Rosenberg & Ringel, 1986; Bader & Kerzner, 1999; Ho et al, 1998).
    b) All of these cases involved patients who had ingested large volumes of syrup of ipecac for weeks to months. In general, the myopathy appears to be reversible when ipecac was stopped (Mateer et al, 1985; Moldawsky, 1985; Palmer & Guay, 1985; Friedman et al, 1987; Ho et al, 1998; Schneider et al, 1996). Although rare, chronic ipecac exposure can occur in children following intentional misuse by parents or caretakers (Carter et al, 2006; Wagner & Bowers, 2006).
    c) Electron microscopy of skeletal muscle biopsies may reveal foci of Z-band degeneration (Schneider et al, 1996).
    B) DECREASED MUSCLE TONE
    1) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) Hypotonia, profound muscle weakness, and the absence of deep tendon reflexes have been reported as a result of chronic emetine intoxication. The toxic neuromuscular effects of emetine may be delayed for up to a week prior to manifestation and may require up to 30 days to resolve.
    b) CASE REPORTS
    1) PEDIATRIC: Progressive proximal weakness in all extremities, along with an elevated creatine kinase level (greater than 20,000 International Units/L) were observed in a 9-year-old boy chronically exposed to syrup of ipecac by his parent. A muscle biopsy showed areas of necrotizing myopathy which was consistent with rhabdomyolysis. The patient gradually improved with supportive care (Wagner & Bowers, 2006; Carter et al, 2006).
    2) PEDIATRIC: Profound weakness in proximal muscles, absence of all deep tendon reflexes, and an inability to hold the head erect were described in a 15-month-old infant after ingesting an unknown amount of ipecac over a period of a few days (Carraccio et al, 1993).
    3) PEDIATRIC: Hypotonia was noted in a 6-week-old girl whose mother had added ipecac syrup to the expressed breast milk that was being fed to her (Berkner et al, 1988).
    C) INCREASED CREATINE KINASE LEVEL
    1) WITH POISONING/EXPOSURE
    a) Elevated creatine kinase levels may be observed following chronic ipecac exposure (Vanin, 1992).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS316-42-7 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Qualitative emetine analysis has been of value for the diagnosis of cases of chronic ingestion of ipecac. However, these levels are not readily available and cannot be used to guide therapy.
    B) Monitor fluid and electrolyte balance if protracted emesis occurs. Monitor CK in patients with evidence of myopathy (weakness or muscle pain).
    C) Obtain an ECG in patients with evidence of chronic poisoning. An echocardiogram may also be indicated in patients with evidence of cardiomyopathy.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitor fluid and electrolyte balance if protracted emesis occurs. Monitor CK in patients with evidence of myopathy (weakness or muscle pain).
    2) Plasma levels of emetine may be useful in substantiating cases of chronic poisoning (particularly in the setting of child abuse), but are not readily available and cannot be used to guide therapy.
    4.1.3) URINE
    A) URINARY LEVELS
    1) Emetine was detected in the urine specimen of a 15-month-old infant 5 weeks after the ingestion of an unknown amount of ipecac (Carraccio et al, 1993). It was also observed in a child chronically exposed to ipecac due to Munchausen Syndrome by proxy (Carter et al, 2006; Wagner & Bowers, 2006).
    2) In 12 adult volunteers, ipecac alkaloids (cephaeline and emetine) could be detected in the urine 2 weeks after receiving a single 20 or 30 mL dose of ipecac; they could be detected in the urine 12 weeks after exposure in one subject who received a single 20 mL dose but did not vomit (Yamashita et al, 2002). This prolonged excretion may be useful in establishing the diagnosis in cases of Munchausen or Munchausen by proxy.
    4.1.4) OTHER
    A) OTHER
    1) ECG
    a) Obtain an ECG in patients with evidence of chronic poisoning.
    2) ECHOCARDIOGRAM
    a) Obtain an echocardiogram in patients with evidence of cardiomyopathy following chronic poisoning (Steffen et al, 2007).
    3) MUSCLE BIOPSY
    a) Muscle biopsy (skeletal or cardiac) may be useful to evaluate patients with myopathy secondary to chronic poisoning (Carter et al, 2006; Wagner & Bowers, 2006).
    1) In a case of intentional ipecac poisoning of a child, a muscle biopsy showed areas of necrotizing myopathy and reddish inclusions (in the area of trichrome-stained segments) that were consistent with rhabdomyolysis (Carter et al, 2006).

Methods

    A) OTHER
    1) Blood and urine levels of emetine and cephadine can be measured after ingestion of ipecac in most patients (Moran et al, 1984) and have been useful in the diagnosis of some poisoning cases (Carter et al, 2006; Wagner & Bowers, 2006; Lachman et al, 1989).
    a) In cases of suspected poisoning, a urine drug screen or a serum screen for ipecac markers should be obtained (Carter et al, 2006).
    2) High performance liquid chromatography/tandem mass spectrometry can be used to screen for ipecac serum markers in urine or serum or plasma.

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) Symptomatic patients (eg, aspiration pneumonia, intestinal obstruction) should be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) A minor exposure (30 mL or less) can likely be managed at home. Persistent vomiting may require assessment in a healthcare facility especially in young children or in individuals that are debilitated or the elderly.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a specialist for assistance in managing patients with evidence of aspiration pneumonia, dysrhythmias or bowel obstruction or in whom the diagnosis is unclear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Symptomatic patients or those with self harm ingestions should be sent to a health care facility for evaluation and treatment as necessary.

Monitoring

    A) Qualitative emetine analysis has been of value for the diagnosis of cases of chronic ingestion of ipecac. However, these levels are not readily available and cannot be used to guide therapy.
    B) Monitor fluid and electrolyte balance if protracted emesis occurs. Monitor CK in patients with evidence of myopathy (weakness or muscle pain).
    C) Obtain an ECG in patients with evidence of chronic poisoning. An echocardiogram may also be indicated in patients with evidence of cardiomyopathy.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Decontamination is not indicated.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Gastrointestinal decontamination is not necessary and is not likely to be of use, since the primary effect of acute ingestion is vomiting.
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment is symptomatic and supportive.
    B) FLUID/ELECTROLYTE BALANCE REGULATION
    1) Fluids may be administered to overcome dehydration and shock. Monitor electrolytes when excessive fluid loss has occurred.
    C) MONITORING OF PATIENT
    1) Qualitative emetine analysis has been of value for the diagnosis of cases of chronic ingestion of ipecac. However, these levels are not readily available and cannot be used to guide therapy.
    2) Monitor fluid and electrolyte status carefully in symptomatic patients. Monitor CK in patients with evidence of cardiomyopathy (muscle weakness or pain).
    3) Assess bowel function following an overdose; monitor for abdominal pain, cramping or distension; prolonged vomiting; diarrhea; or evidence of bowel obstruction.
    4) Obtain an ECG in patients with evidence of chronic poisoning. An echocardiogram may also be indicated in patients with evidence of cardiomyopathy.
    D) 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).
    4) DOBUTAMINE
    a) DOSE: ADULT: Infuse at 5 to 10 micrograms/kilogram/minute IV. PEDIATRIC: Infuse at 2 to 20 micrograms/kilogram/minute IV or intraosseous, titrated to desired effect (Peberdy et al, 2010; Kleinman et al, 2010).
    b) CAUTION: Decrease infusion rate if ventricular ectopy develops (Prod Info dobutamine HCl 5% dextrose intravenous injection, 2012).
    5) Patients with cardiomyopathy from chronic ipecac exposure may respond poorly to therapy for hypotension.
    E) VENTRICULAR ARRHYTHMIA
    1) VENTRICULAR DYSRHYTHMIAS SUMMARY
    a) Obtain an ECG, institute continuous cardiac monitoring and administer oxygen. Evaluate for hypoxia, acidosis, and electrolyte disorders (particularly hypokalemia, hypocalcemia, and hypomagnesemia). Lidocaine and amiodarone are generally first line agents for stable monomorphic ventricular tachycardia, particularly in patients with underlying impaired cardiac function. Amiodarone should be used with caution if a substance that prolongs the QT interval and/or causes torsades de pointes is involved in the overdose. Unstable rhythms require immediate cardioversion.
    2) LIDOCAINE
    a) LIDOCAINE/INDICATIONS
    1) Ventricular tachycardia or ventricular fibrillation (Prod Info Lidocaine HCl intravenous injection solution, 2006; Neumar et al, 2010; Vanden Hoek et al, 2010).
    b) LIDOCAINE/DOSE
    1) ADULT: 1 to 1.5 milligrams/kilogram via intravenous push. For refractory VT/VF an additional bolus of 0.5 to 0.75 milligram/kilogram can be given at 5 to 10 minute intervals to a maximum dose of 3 milligrams/kilogram (Neumar et al, 2010). Only bolus therapy is recommended during cardiac arrest.
    a) Once circulation has been restored begin a maintenance infusion of 1 to 4 milligrams per minute. If dysrhythmias recur during infusion repeat 0.5 milligram/kilogram bolus and increase the infusion rate incrementally (maximal infusion rate is 4 milligrams/minute) (Neumar et al, 2010).
    2) CHILD: 1 milligram/kilogram initial bolus IV/IO; followed by a continuous infusion of 20 to 50 micrograms/kilogram/minute (de Caen et al, 2015).
    c) LIDOCAINE/MAJOR ADVERSE REACTIONS
    1) Paresthesias; muscle twitching; confusion; slurred speech; seizures; respiratory depression or arrest; bradycardia; coma. May cause significant AV block or worsen pre-existing block. Prophylactic pacemaker may be required in the face of bifascicular, second degree, or third degree heart block (Prod Info Lidocaine HCl intravenous injection solution, 2006; Neumar et al, 2010).
    d) LIDOCAINE/MONITORING PARAMETERS
    1) Monitor ECG continuously; plasma concentrations as indicated (Prod Info Lidocaine HCl intravenous injection solution, 2006).
    3) AMIODARONE
    a) AMIODARONE/INDICATIONS
    1) Effective for the control of hemodynamically stable monomorphic ventricular tachycardia. Also recommended for pulseless ventricular tachycardia or ventricular fibrillation in cardiac arrest unresponsive to CPR, defibrillation and vasopressor therapy (Link et al, 2015; Neumar et al, 2010). It should be used with caution when the ingestion involves agents known to cause QTc prolongation, such as fluoroquinolones, macrolide antibiotics or azoles, and when ECG reveals QT prolongation suspected to be secondary to overdose (Prod Info Cordarone(R) oral tablets, 2015).
    b) AMIODARONE/ADULT DOSE
    1) For ventricular fibrillation or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy give an initial dose of 300 mg IV followed by 1 dose of 150 mg IV. For stable ventricular tachycardias: Infuse 150 milligrams over 10 minutes, and repeat if necessary. Follow by a 1 milligram/minute infusion for 6 hours, then a 0.5 milligram/minute. Maximum total dose over 24 hours is 2.2 grams (Neumar et al, 2010).
    c) AMIODARONE/PEDIATRIC DOSE
    1) Infuse 5 milligrams/kilogram as a bolus for pulseless ventricular tachycardia or ventricular fibrillation; may repeat twice up to 15 mg/kg. Infuse 5 milligrams/kilogram over 20 to 60 minutes for perfusing tachycardias. Maximum single dose is 300 mg. Routine use with other drugs that prolong the QT interval is NOT recommended (Kleinman et al, 2010).
    d) ADVERSE EFFECTS
    1) Hypotension and bradycardia are the most common adverse effects (Neumar et al, 2010).
    4) PROCAINAMIDE
    a) PROCAINAMIDE/INDICATIONS
    1) An alternative drug in the treatment of PVCs or recurrent ventricular tachycardia when lidocaine is contraindicated or not effective. It should be avoided when the ingestion involves agents with quinidine-like effects (e.g. tricyclic antidepressants, phenothiazines, chloroquine, antidysrhythmics) and when the ECG reveals QRS widening or QT prolongation suspected to be secondary to overdose(Neumar et al, 2010; Vanden Hoek,TLet al,null).
    b) PROCAINAMIDE/ADULT LOADING DOSE
    1) 20 to 50 milligrams/minute IV until dysrhythmia is suppressed or toxicity develops from procainamide (hypotension develops or the QRS is widened by 50%), or a total dose of 17 milligrams/kilogram is given (1.2 grams for a 70 kilogram person) (Neumar et al, 2010).
    2) ALTERNATIVE DOSING: 100 mg every 5 minutes until dysrhythmia is controlled, or toxicity develops from procainamide (hypotension develops or the QRS is widened by 50%) or 17 mg/kg have been given (Neumar et al, 2010).
    3) MAXIMUM DOSE: 17 milligrams/kilogram (Neumar et al, 2010).
    c) PROCAINAMIDE/CONTROLLED INFUSION
    1) In conscious patients, procainamide should be administered as a controlled infusion (20 milligrams/minute) because of the risk of QT prolongation and its hypotensive effects (Link et al, 2015)
    d) PROCAINAMIDE/ADULT MAINTENANCE DOSE
    1) 1 to 4 milligrams/minute via an intravenous infusion (Neumar et al, 2010).
    e) PROCAINAMIDE/PEDIATRIC LOADING DOSE
    1) 15 milligrams/kilogram IV/Intraosseously over 30 to 60 minutes; discontinue if hypotension develops or the QRS widens by 50% (Kleinman et al, 2010).
    f) PROCAINAMIDE/PEDIATRIC MAINTENANCE DOSE
    1) Initiate at 20 mcg/kg/minute and increase in 10 mcg/kg/minute increments every 15 to 30 minutes until desired effect is achieved; up to 80 mcg/kg/minute (Bouhouch et al, 2008; Ratnasamy et al, 2008; Mandapati et al, 2000; Luedtke et al, 1997; Walsh et al, 1997).
    g) PROCAINAMIDE/PEDIATRIC MAXIMUM DOSE
    1) 2 grams/day (Bouhouch et al, 2008; Ratnasamy et al, 2008; Mandapati et al, 2000; Luedtke et al, 1997; Walsh et al, 1997).
    h) MONITORING PARAMETERS
    1) ECG, blood pressure, and blood concentrations (Prod Info procainamide HCl IV, IM injection solution, 2011). Procainamide can produce hypotension and QT prolongation (Link et al, 2015).
    i) AVOID
    1) Avoid in patients with QT prolongation and CHF (Neumar et al, 2010).
    F) DIARRHEA
    1) Diarrhea should be treated symptomatically. Avoid Lomotil(R) in children.

Enhanced Elimination

    A) SUMMARY
    1) No mechanism to enhance excretion is known.

Range Of Toxicity

Summary

    A) TOXICITY: As much as 105 mL of the syrup of ipecac has been retained by one child with only minor ECG changes. Some adults have repeatedly ingested 30 to 60 mL of the syrup and have not developed any acute toxicity other than vomiting. Acute ingestion of as little as 10 mL of the fluid extract (no longer commercially available) form has been associated with fatalities. CHRONIC: Ingestion of 12 mL 3 to 4 times/week resulted in reversible myopathy in one patient. Fatalities have been reported following chronic use of up to 60 mL/day or more for weeks to months. Emetine-related deaths in adults usually occurs with ingestions of greater than 1.25 g total; however most of these patients have severe underlying pathology related to an eating disorder.
    B) THERAPEUTIC DOSE: ADULTS AND ADOLESCENTS: 15 to 30 mL followed immediately by 240 mL of water; may repeat dose in 20 to 30 minutes if emesis does not occur. PEDIATRIC: CHILDREN 1 TO 12 YEARS OF AGE: 15 mL of ipecac syrup, preceded or followed by 4 to 8 ounces (120 to 240 mL) of water. CHILDREN 6 TO 12 MONTHS OF AGE: 5 to 10 mL of ipecac syrup preceded or followed by 4 to 8 ounces (120 to 240 mL) of water. CHILDREN UP TO 6 MONTHS OF AGE: Ipecac should only be administered under the supervision of a physician.

Therapeutic Dose

    7.2.1) ADULT
    A) CURRENT RECOMMENDATIONS
    1) The American Academy of Poison Control Centers (AAPCC) position statement is as follows: ipecac should not be routinely administered in the management of poisoned patients (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004; Anon, 1997).
    B) DOSING
    1) INDICATION: Ipecac should only be considered if a recent ingestion (less than 60 minutes) as the effect can diminish with time. Ipecac is contraindicated in patients that are unable to protect their airway, following the ingestion of a hydrocarbon or a corrosive substance or debilitated patients (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    2) ADOLESCENTS AND ADULTS: 15 to 30 mL orally followed immediately by 240 mL of water (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004). The dose may be repeated in 20 to 30 minutes if emesis does not occur. The ingestion of milk or the use of ipecac that has exceeded the expiration date is not a contraindication for use (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    C) ADMINISTRATION GUIDELINES
    1) SUMMARY: Administration of ipecac before or after fluids (Bukis et al, 1978), or with warm or cool fluids (Spiegel et al, 1979) has no effect on the response.
    2) The AMOUNT OF FLUID administered with syrup of ipecac has not been shown to affect efficacy. Several studies have shown that the amount of fluid given with ipecac has no relationship to the time to emesis or success rate (Grande & Ling, 1987; Grbcich et al, 1986b; Bobbink et al, 1986).
    3) Administration of CARBONATED BEVERAGES with ipecac syrup resulted in greater abdominal distention, but no increase in adverse effects or decrease in efficacy, when compared to water in a small series of 24 children (Uden et al, 1981). The FDA has concluded that carbonated beverages can be safely administered after ingesting ipecac syrup (Anon, 1985).
    4) MILK: One prospective study compared milk as the diluent compared to fluids. Volumes administered were similar. There was no difference in onset, number of episodes, or duration of vomiting. Side effects were also similar (Klein-Schwartz et al, 1991).
    7.2.2) PEDIATRIC
    A) CURRENT RECOMMENDATIONS
    1) PREHOSPITAL: The use of syrup of ipecac is NO longer routinely recommended in the home by the American Academy of Pediatrics. If a child has a potentially poisonous ingestion a Poison Control Center should be contacted immediately for consultation and guidance (Anon, 2003; Meadows-Oliver, 2004).
    2) The American Academy of Poison Control Centers (AAPCC) position statement is as follows: ipecac should not be routinely administered in the management of poisoned patients (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004; Anon, 1997).
    B) DOSING
    1) CHILDREN 1 TO 12 YEARS OF AGE: 15 mL of ipecac syrup, preceded or followed by 4 to 8 ounces (120 to 240 mL) of water (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    2) In a study comparing 15 milliliters and 30 milliliters doses in children, 8.8% of children receiving the lower dose did not vomit within 30 minutes. With a repeat dose of 15 milliliters, 99.8% of children receiving the lower dose vomited compared to 99.9% of children receiving the larger dose. Assessment of ipecac toxicity or side effects was not performed in this study (Krenzelok & Dean, 1987).
    3) CHILDREN 6 TO 12 MONTHS OF AGE: 5 to 10 mL of ipecac syrup preceded or followed by 4 to 8 ounces (120 to 240 mL) of water (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    4) CHILDREN UP TO 6 MONTHS OF AGE: Ipecac should only be administered under the supervision of a physician (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).
    5) GENERAL: The dose may be repeated in 20 to 30 minutes in all age groups, if emesis does not occur. The ingestion of milk or the use of ipecac that has exceeded the expiration date is not a contraindication for use (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004).

Minimum Lethal Exposure

    A) SPECIFIC SUBSTANCE
    1) FLUID EXTRACT: Several deaths have been reported from the use of ipecac FLUID EXTRACT instead of ipecac syrup; the fluid extract is 14 times more potent than the syrup preparation (Manno & Manno, 1977). As little as 10 mL of the fluid extract form has been associated with fatalities. The fluid extract is not currently commercially available in the US. .
    2) The fatal dose of emetine is estimated to be 19 mg/kg of body weight (Isner et al, 1985), but there is a wide variability in individual susceptibility (Romig, 1985). Another group estimated the lethal dose of emetine to be 10 to 25 mg/kg of body weight (Anderson & Reed, 1934).
    3) It is estimated that 600 to 1250 mg (estimated ingestion of 30 to 60 bottles of a 30 mL bottle) of emetine may be lethal in humans. A 30 mL bottle has an estimated 21 to 24 mg of emetine and 31 mg of cephaeline (American Academy of Clinical Toxicology & European Association of Poisons Centers and Clinical Toxicologists, 2004; Lohr, 1987; Vanin, 1992). In another study, a preparation of ipecac syrup (commercially available) was found to contain 13.9 mg/30 mL of emetine and 45 mg/30 mL of cephaline (Scharman et al, 2000).
    4) Emetine-related deaths in adults usually occurs with ingestions of greater than 1.25 g total (Adler et al, 1980), although deaths have been reported with estimated total doses of 880 mg (Friedman, 1984). Most of these patients have severe underlying pathology related to an eating disorder.
    5) Cumulative toxicity (eg, myopathy) can develop because emetine is excreted slowly; complete recovery may take 6 to 12 months (Lohr, 1987).
    B) THERAPEUTIC DOSE FATALITIES
    1) A case of an INTRACEREBRAL BLEED in an 84-year-old woman which resulted in death has been reported. This bleed was temporally related to the administration of syrup of ipecac which induced 7 episodes of vomiting over 3 hours (Klein-Schwartz et al, 1984).
    2) CASE REPORT: Gastric rupture and death have been reported in a 2.5-year-old child who received 15 mL of syrup of ipecac to treat an ingestion of one to five chlorpheniramine tablets (Knight & Doucet, 1987).
    3) CASE REPORT: A fatality has been reported following ingestion of syrup of ipecac in a 14-month-old child where vomiting may have caused extrusion of the stomach through a congenital diaphragmatic hernia into the left pleural space resulting in a cardiopulmonary arrest (Robertson, 1979).

Maximum Tolerated Exposure

    A) SUMMARY
    1) Some adults have repeatedly ingested 30 to 60 mL of the syrup and have not developed any acute toxicity other than vomiting; 15 to 30 mL of the syrup is the standard recommended dose to induce emesis.
    2) It is estimated that 500 to 600 mg for 10 days may produce neuromuscular effects (Rollo, 1975).
    3) An estimated dose of approximately 1.25 g of syrup of ipecac can result in myopathy, including cardiomyopathy (Steffen et al, 2007).
    4) In a study of the lifetime consumption of ipecac syrup in patients with bulimia (n=100), individuals with chronic ipecac exposure (2000 lifetime doses) had notable symptoms of myopathy that resulted in difficulty walking and inability to climb stairs. Patients with fewer lifetime doses (400 doses or fewer) did not report muscle weakness (Pope et al, 1986).
    B) CASE REPORTS
    1) A 14-year-old boy developed cardiomyopathy (decreased left ventricular function, an ejection fraction of 34%) and acute myocarditis with difficulty walking and muscle weakness following the intentional ingestion of ipecac to purposely make himself ill. A serum emetine level of 28 mg/mL (normal limit: 2.5 mg/mL) was obtained on admission. Cardiac and muscle function improved after 2 weeks of hospitalization; no permanent sequelae occurred (Rashid, 2006).

Serum Plasma Blood Concentrations

    7.5.2) TOXIC CONCENTRATIONS
    A) TOXIC CONCENTRATION LEVELS
    1) CASE REPORTS
    a) Serum emetine level was 500 ng/mL in a child with ipecac-induced cardiomyopathy. Postmortem levels (2 days later) were serum 400 ng/mL, urine 1700 ng/mL and bile 1800 ng/mL (Andersen et al, 1997).
    b) Postmortem blood emetine and cephaeline levels on a child with ipecac-induced cardiomyopathy were 845 ng/ml and 1200 ng/ml, respectively (Schneider et al, 1996).
    c) A 14-year-old boy developed ipecac-induced cardiomyopathy after intentional misuse. At the time of admission, his serum emetine concentration was 28 mg/mL (normal limit 2.5 mg/mL or less). He recovered following supportive care (Rashid, 2006).

Workplace Standards

    A) ACGIH TLV Values for CAS316-42-7 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS316-42-7 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS316-42-7 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS316-42-7 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Syrup of ipecac exerts its emetic effect by prompting gastric irritation and through a central effect by stimulating the chemoreceptor trigger zone (Silber, 2005; Meester, 1980; Barone et al, 1987)but this action is thought to play a minor role in doses used to treat drug ingestions..
    B) However, the primary emetic effect appears to be mediated peripherally, by a direct irritant action on the gastric mucosa(Moran et al, 1984).
    C) Patients who have ingested antiemetic drugs have responded to ipecac syrup (Manoguerra & Krenzelok, 1978).

Toxicologic Mechanism

    A) Derived from a Central American plant, ipecac has an extensive history of use spanning more than three centuries. Its effects are functions of its alkaloidal contents (emetine 60%, cephaline (varies from an amount equal to, to an amount not twice the content of emetine), cykotrine, hydroipecamine, and ipecamine) as well as occasional impurities. Emetine has enjoyed extensive use in the management of amoebic dysentery.
    B) CARDIAC: Emetine directly depresses myocardial contracts, causes flattened or inverted T-waves, and may prolong Q-T intervals (Moldawsky, 1985).
    C) MYOPATHY
    1) A reversible floccular-shaped loss of myosin ATPase and dehydrogenase has been noted, along with PAS positive, diastase-sensitive material. Microscopy showed Z-band streaming with mitochondria loss (Sugie et al, 1984).
    2) Muscle biopsies show an increase in type 1 fibers, a decrease in average muscle fiber diameter, and isolated necrotic granular basophilic fibers (pp 422-431).

Physicochemical

Molecular Weight

    A) 553.57

References

General Bibliography

    1) 40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.
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