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Syrup of ipecac

Clinical data
Routes of administration	Oral
ATC code	R05CA04 (WHO) V03AB01 (WHO)
Legal status
Legal status	In general: Over-the-counter (OTC)
Identifiers
CAS Number	8012-96-2
ChemSpider	NA
ECHA InfoCard	100.029.439
(what is this?)  (verify)

Syrup of ipecac (/ˈɪpkæk/), commonly referred to as ipecac, is derived from the dried rhizome and roots of the ipecacuanha plant, and is a well known emetic (substance used to induce vomiting).

Preparation

The commercial preparation of ipecac consists of 1/14 of an alcoholic extract of the roots and rhizomes of ipecac root. The rest is composed of glycerin, sugar syrup, and methylparaben. Ipecac root itself is a poison, but due to the normal strengths used and the inability of the patient to keep the solution ingested, it is seldom fatal.

Use

Ipecac was used in cough mixtures as an expectorant or an emetic from the 18th until the early 20th century. Ipecac and opium were used to produce Dover's powder, which was used in syrup form. Ipecac syrup is still used to induce vomiting, though it is no longer widely recommended.

Pediatricians once recommended ipecac be kept in the home as a ready emetic for use in cases of accidental poisoning. Current guidelines from the American Academy of Pediatrics, however, strongly advise against this and in fact recommend the disposal of any syrup of ipecac present in the home. Many toxicological associations have also issued position papers recommending against its use as a first-line treatment for most ingested poisons, because there has been no evidence that syrup of ipecac actually helps improve the outcome in cases of poisoning. Moreover, accidental overdose of ipecac can result when administered in the home.

A 2005 review by an HRSA-funded scientific panel concluded that vomiting alone does not reliably remove poisons from the stomach. The study suggested that indications for use of ipecac syrup were rare, and patients should be treated by more effective and safer means. Additionally, its potential side effects, such as lethargy, can be confused with the poison’s effects, complicating diagnosis. Ipecac may also delay the administration or reduce the effectiveness of other treatments, such as activated charcoal, whole bowel irrigation, or oral antidotes.

Misuse

Ipecac has been used by individuals with bulimia nervosa as a means to achieve weight loss through induced defensive vomiting. Repeated use in this manner is believed to cause damage to the heart and muscles, which can ultimately result in the user's death. Misuse of ipecac has been blamed for the death of well-known singer Karen Carpenter in 1983. It has also been used as an agent for Münchausen syndrome by proxy.

Mechanism of action

The actions of ipecac are mainly those of its major alkaloids, emetine (methylcephaeline) and cephaeline. They both act locally by irritating the gastric mucosa and centrally by stimulating the medullary chemoreceptor trigger zone to induce vomiting.

Discontinuation

Ipecac has been found to have minimal health benefits, and ultimately ineffective at purging the body of poisonous substances, and as such global production of the syrup has been stopped. As the ASHP puts it, "Ipecac syrup is no longer recommended for routine management of outpatient ingestions of medications or other chemicals".

A position statement cited several times outlines critical details of its effectiveness, including this direct quote: "In experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned. There are insufficient data to support or exclude ipecac administration soon after poison ingestion. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. Ipecac should not be administered to a patient who has a decreased level or impending loss of consciousness or who has ingested a corrosive substance or hydrocarbon with high aspiration potential."

References

1. ^ Committee on Injury, Violence, and Poison Prevention (1994), "Office-Based Counseling for Injury Prevention" (PDF), Pediatrics, 94 (4): 566–567, PMID 7936874{{citation}}: CS1 maint: multiple names: authors list (link)
2. Committee on Injury, Violence, and Poison Prevention (2003), "Poison Treatment in the Home", Pediatrics, 112 (5): 1182–1185, doi:10.1542/peds.112.5.1182, PMID 14595067{{citation}}: CS1 maint: multiple names: authors list (link)
3. Manoguerra, A S; Krenzelok, E P; McGuigan, M; Lheureux, P (2004), "AACT/EAPCCT position paper: ipecac syrup", Clinical Toxicology, 42 (2): 133–43, doi:10.1081/CLT-120037421, PMID 15214617. {{citation}}: More than one of |author= and |last1= specified (help)
4. Bateman, D N (1999), "Gastric decontamination—a view for the millennium", British Medical Journal, 16 (2), BAEM: 84, doi:10.1136/emj.16.2.84, PMC 1343284, PMID 10191436
5. Manoguerra, A S; Cobaugh, D J; Guidelines for the Management of Poisoning Consensus Panel (2005), "Guideline on the Use of Ipecac Syrup in the Out-of-Hospital Management of Ingested Poisons", Clinical Toxicology, 43 (1): 1–10, doi:10.1081/CLT-200046735, PMID 15732439 {{citation}}: More than one of |author= and |last1= specified (help)
6. Silber, T J (2005), "Ipecac syrup abuse, morbidity, and mortality: Isn't it time to repeal its over-the-counter status?", Journal of Adolescent Health, 37 (3): 256–260, doi:10.1016/j.jadohealth.2004.08.022, PMID 16109351, retrieved 2008-05-02
7. Schmidt R |Karen Carpenter's tragic story |The Guardian 24 October 2010 |url=http://www.guardian.co.uk/books/2010/oct/24/karen-carpenter-anorexia-book-extract
8. Shannon M (2003), "The demise of ipecac", Pediatrics, 112 (5): 1180–1, doi:10.1542/peds.112.5.1180, PMID 14595066. {{citation}}: Unknown parameter |month= ignored (help)
9. http://www.ashp.org/Import/PRACTICEANDPOLICY/PracticeResourceCenters/DrugShortages/GettingStarted/DrugsNoLongerAvailable/Bulletin.aspx?id=468
10. . doi:10.3109/15563659709162567. PMID 9482425. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)

External links

• AAP policy on Poison Treatment in the Home
• Chemical Poisoning and Syrup of Ipecac

• Ill-formatted IPAc-en transclusions
• Emetics