Ipecac (Oral-Local)


VA CLASSIFICATION
Primary: GA601

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).



Category:


Emetic—

Indications

Accepted

Toxicity, nonspecific (treatment)—Ipecac syrup is indicated as an emetic for emergency use in the treatment of drug overdose and in some cases of poisoning. Ipecac should not be used if strychnine or corrosives such as alkalies (lye) or strong acids have been ingested. Use in strychnine poisoning may precipitate seizures, and use in corrosive poisoning may cause additional injury to the esophagus. {02} {04} {07}
—Also, ipecac should not be used in semiconscious or unconscious persons since there is an increased risk that the vomited material may enter the lungs and cause pneumonia. {02} {07} {08}
—In addition, ipecac is usually not used in patients who have ingested petroleum distillates such as kerosene, gasoline, coal oil, fuel oil, paint thinner, or cleaning fluid {04} because of the high risk of pulmonary aspiration, possibly resulting in pneumonia; however, this is controversial. The benefits of ipecac may outweigh the risks of aspiration or toxic reactions from the petroleum distillate, depending on the amount ingested and the relative toxicity of the petroleum distillate or the chemical dissolved in it. {02} {07}


Pharmacology/Pharmacokinetics

Mechanism of action/Effect:

The actions of ipecac are mainly those of its major alkaloids, emetine and cephaeline. They act locally by irritating the gastric mucosa and centrally by stimulating the medullary chemoreceptor trigger zone to induce vomiting. {04} {20} {21}

Onset of action:

20 to 30 minutes. {02} {08}

Duration of action:

20 to 25 minutes.

Elimination:
    Emetine—Eliminated from body very slowly; may be detected in urine up to 60 days after ipecac use. {01}


Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Studies have not been done in humans.

Studies have not been done in animals. {02}

FDA Pregnancy Category C.

Breast-feeding

It is not known whether ipecac is distributed into breast milk. However, problems in humans have not been documented. {02}

Pediatrics

In children under 1 year of age, there is an increased risk of aspiration of vomitus. Medical advice and/or supervision on proper positioning to avoid aspiration is important in this age group. {05} {07} {12} {17}


Geriatrics


Appropriate studies performed to date have not demonstrated geriatrics-specific problems that would limit the usefulness of ipecac in the elderly.

Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.

Antiemetics    (prior ingestion of these medications may decrease the emetic response to ipecac {08})


Beverages, carbonated    (concurrent use with ipecac is not recommended since these beverages may cause distention of the stomach)


Charcoal, activated    (if both ipecac and activated charcoal are to be used in the treatment of poisoning, it is generally recommended that activated charcoal be administered only after vomiting has been induced and completed; {04} however, in some clinical trials in which activated charcoal was administered pre-emesis 10 minutes after high doses of ipecac, the emetic properties of ipecac were not inhibited {02} {21} {23})


Milk or milk products    (concurrent use is not recommended since milk has been reported to decrease the effectiveness of ipecac {21})


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, this medication should not be used when the following medical problems exist:
» Any condition in which there is an increased risk of aspiration of vomitus, such as:
» Decreased patient alertness or
» Depressed gag reflex or
» Seizures or history of{04}{08} or
» Shock{05} or
» Unconsciousness    (risk of aspiration pneumonia {02} {08} {22})


» Ingestion of corrosive materials, such as alkalies (lye) or strong acids    (vomiting may cause additional injury to the esophagus {02} {04} {22})


Risk-benefit should be considered when the following medical problems exist
Heart disease    (increased risk of tachycardia, hypotension, precordial chest pain, dyspnea, and electrocardiogram (ECG) abnormalities if ipecac is not vomited {04})


» Ingestion of petroleum distillates, such as kerosene, gasoline, coal oil, fuel oil, paint thinner, or cleaning fluid    (risk of aspiration pneumonia {02} {04} {07})


Strychnine poisoning    (increased risk of seizures {07})




Side/Adverse Effects

Note: Toxic myopathy, cardiac toxicity, and several deaths have been reported as a result of the chronic use of ipecac among young women with anorexia nervosa, bulimia, and related eating disorders. These patients used ipecac as a means of inducing emesis to lose weight. {02} {13} {14} {15} {16} {18}




Overdose
For more information on the management of overdose or unintentional ingestion, contact a Poison Control Center (see Poison Control Center Listing ).

Clinical effects of overdose
The following effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive (may also be symptoms of chronic abuse {02} {04} {19}):
    
Diarrhea
    
fast or irregular heartbeat
    
nausea or vomiting, continuing more than 30 minutes
    
stomach cramps or pain
    
troubled breathing
    
unusual tiredness or weakness
    
weakness, aching, and stiffness of muscles, especially those of the neck, arms, and legs

Note: Cardiac and muscle disorders are related to emetine toxicity.




Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Ipecac (Oral) .

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
» Calling physician, poison control center, or emergency room before taking medication
»   Conditions affecting use, especially:





Use in children—Increased risk of aspiration of vomitus in children under 1 year of age

Other medical problems, especially any condition in which there is an increased risk of aspiration of vomitus, and ingestion of corrosive materials or petroleum distillates

Proper use of this medication
» Importance of not taking more medication than recommended on the label or otherwise directed

» Not giving medication to semiconscious or unconscious persons

Importance of drinking water immediately after taking medication

» Avoiding concurrent use with milk or carbonated beverages

Getting medical attention immediately if vomiting does not occur within 20 minutes after second dose

» Taking activated charcoal only after vomiting has been induced by this medication and completed, if both are to be used

» Proper dosing

» Proper storage


Side/adverse effects
Signs of potential side effects, especially cardiac and muscle disorders related to emetine toxicity (with chronic abuse)


General Dosing Information
To increase the emetic action of ipecac, it is recommended that adults drink 1 full glass (240 mL) {02} {03} {07} {21} of water and children drink 1/2 to 1 full glass (120 to 240 mL) of water immediately after taking the ipecac syrup. In young and frightened children, water may be given before the ipecac syrup if necessary.

No more than 2 doses of ipecac syrup should be taken since ipecac can be cardiotoxic.


Oral Dosage Forms

IPECAC SYRUP USP

Note: Ipecac Fluidextract and Ipecac Tincture have been replaced by Ipecac Syrup, the preferred dosage form. Ipecac Fluidextract is 14 times more concentrated than Ipecac Syrup, and is not recommended for use because of its high potency and toxicity. {04}


Usual adult and adolescent dose
Emetic
Oral, 15 to 30 mL, followed immediately by one full glass (240 mL) of water. Dose may be repeated after twenty to thirty minutes if emesis does not occur. If emesis does not occur after the second dose, gastric lavage should be performed. {02} {04} {21}


Usual pediatric dose
Emetic {01} {17}
Children up to 6 months of age: Ipecac syrup should be administered only under the supervision of a physician.

Children 6 months to 1 year of age: Oral, 5 to 10 mL, preceded or followed by one-half to one full glass (120 to 240 mL) of water.

Children 1 to 12 years of age: Oral, 15 mL, preceded or followed by one-half to one full glass (120 to 240 mL) of water.

Note: Doses may be repeated after twenty to thirty minutes if emesis does not occur. {04} {09} If emesis does not occur after the second dose, gastric lavage should be performed. {04}
For children 6 months to 1 year of age, professional advice on proper positioning to avoid aspiration of vomitus is important.



Strength(s) usually available
U.S.—


15 mL (OTC)[Generic]


30 mL (OTC)[Generic]

Canada—


15 mL (OTC)[Generic]


30 mL (OTC)[Generic]

Note: Each mL of ipecac syrup contains 1.23 to 1.57 mg of the total ether-soluble alkaloids of ipecac.
Alcohol content ranges from 1 to 2%.


Packaging and storage:
Store preferably at a temperature below 25 °C (77 °F), in a tight container.

Note: Containers intended for sale to the public without prescription contain not more than 30 mL of ipecac syrup.


Note: If ipecac syrup is to be used as an emetic for emergency use in poisoning, consider providing on the label the telephone number for physician, poison control center, or emergency room.




Revised: 08/04/1994



References
  1. Physician's Drug Alert 1985; Aug: 63.
  1. Ipecac syrup package insert (Eli Lilly—US), Rev 1/16/89.
  1. Panel comment.
  1. Syrup of ipecac in poisoning. Medifile 1993; 7: 84.
  1. McEvoy GK, editor. AHFS Drug information 88. Bethesda, MD: American Society of Hospital Pharmacists, 1988: 1642.
  1. Not used.
  1. Aronow R, editor. Handbook of common poisonings in children. 2nd ed. Evanston, IL: American Academy of Pediatrics: 3-4.
  1. The British Columbia Drug and Poison Information Centre. Poison management manual. Ottawa: Canadian Pharmaceutical Association, 1984: 1-2.
  1. Krenzelok EP, Dean BS. Effectiveness of 15-mL versus 30-mL doses of syrup of ipecac in children. Clin Pharm 1987; 6: 715-7.
  1. Not used.
  1. Berkner P, Kastner T, Skolnick L. Chronic ipecac poisoning in infancy: a case report. Pediatrics 1988; 82: 384-5.
  1. Knight KM, Doucet HJ. Gastric rupture and death caused by ipecac syrup. South Med J 80: 786-7.
  1. Schiff RJ, Wurzel CL, Brunson SC, et al. Death due to chronic syrup of ipecac use in a patient with bulimia. Pediatrics 1986; 78: 412-6.
  1. Palmer ER, Guay AT. Reversible myopathy secondary to abuse of ipecac in patients with major eating disorders. N Engl J Med 1985; 313: 1457-9.
  1. Mateer J, et al. Reversible ipecac myopathy. Arch Neurol 1985; 42: 188-90.
  1. Thyagarajan D, Day BJ, Wodak J, et al. Emetine myopathy in a patient with an eating disorder. Med J Aust 1993; 159: 757-60.
  1. Litovitz TL, Klein-Schwartz W, Oderda GM, et al. Ipecac administration in children younger than 1 year of age. Pediatrics 1985; 76: 761-4.
  1. Dresser LP, Massey EW, Johnson EE, et al. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatr 1993; 56: 560-2.
  1. Manno BR, Manno JE. Toxicology of ipecac: a review. Clin Toxicol 1977; 10: 221-42.
  1. Moran DM, Crouch DJ, Finkle BS, et al. Absorption of ipecac alkaloids in emergency patients. Ann Emerg Med 1984; 13: 1100-2.
  1. AMA Drug evaluations. 6th ed. Chicago: American Medical Association, September 1986.
  1. Wheeler-Usher DH. Gastric emptying. Risk versus benefit in the treatment of acute poisoning. Med Toxicol 1986; 1: 142-53.
  1. Krenzelok EP, Freedman GE, Paternak S. Preserving the emetic effect of syrup of ipecac with concurrent activated charcoal administration: a preliminary study. Clin Toxicol 1986; 24: 159-66.
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