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.

Ipecac should only be considered for the treatment of a patient in whom (Manoguerra & Cobaugh, 2005):

• There is no contraindication.
• There is a substantial chance of serious toxicity based on the substance quantity ingested.
• There is no apparent alternative available to decrease GI absorption.
• There will be a delay of more than 1 hour before a patient can reach an emergency medical facility.
• Ipecac can be administered within 30 to 90 minutes of ingestion.

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).

AMERICAN ACADEMY OF PEDIATRICS RECOMMENDATION

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).

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).

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).

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).

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).

Ipecac has been reported to reduce the absorption of cimetidine and pindolol in volunteers by 75% and 60%, respectively (Neuvonen & Olkkola, 1984).

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).

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).

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%.

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.

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).

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).

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.

STUDIES

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.

Only the statutory or final RQ is shown. For more information, see 40 CFR table 302.4.

1/10,000

Amount necessary to be covered by this standard. See 40 CFR 355.30.

d: Revised TPQ based on new or re-evaluated toxicity data, April 22, 1987.

TEEL-0: The threshold concentration below which most people will experience no adverse health effects.

TEEL-1: The airborne concentration (expressed as ppm [parts per million] or mg/m(3) [milligrams per cubic meter]) of a substance above which it is predicted that the general population, including susceptible individuals, could experience notable discomfort, irritation, or certain asymptomatic, nonsensory effects. However, these effects are not disabling and are transient and reversible upon cessation of exposure.

TEEL-2: The airborne concentration (expressed as ppm or mg/m(3)) of a substance above which it is predicted that the general population, including susceptible individuals, could experience irreversible or other serious, long-lasting, adverse health effects or an impaired ability to escape.

TEEL-3: The airborne concentration (expressed as ppm or mg/m(3)) of a substance above which it is predicted that the general population, including susceptible individuals, could experience life-threatening adverse health effects or death.