Ipecac Syrup

Class: Emetics
VA Class: GA600
CAS Number: 8012-96-2

Introduction

Central and local emetic;a b contains the major alkaloids emetine and cephaeline.a

Uses for Ipecac Syrup

Acute Poisoning

Induce vomiting in the early management of acute oral drug overdosage and in certain cases of oral poisoning.a b Does not preclude using other appropriate measures in the emergency treatment of poisonings.a

If attempting to manage an acute poisoning in a medically unsupervised setting, contact a poison control center (800-222-1222), emergency medical facility, or other qualified healthcare professional before administering ipecac.a b

Use may be justifiable in certain cases where benefit outweighs potential risk130 132 133 (e.g., when drug is not contraindicated, if substantial risk of serious toxicity, if no effective alternative treatment available, if delay is >1 hour before emergency treatment, if ipecac syrup administered within 30–90 minutes of ingestion, and if ipecac syrup is unlikely to affect more definitive treatments).132 In these circumstances, administer only after specific recommendation by poison control center, emergency medical facility, or other qualified clinician.132

Emesis may not evacuate all toxic material from the GI tract; observe patients carefully for signs of increasing intoxication.a

Slideshow: Worried About Ebola? You’re More Likely to Get These 10 Serious Infections

Once considered a mainstay in the management of overdosage and poisoning in adults and children; however, many experts now consider ipecac syrup to have a limited role in the emergency management of poisoned patients and recommend selective, rather than routine, use.132 133 146

Insufficient evidence of improved outcomes;132 133 use of ipecac syrup may delay administration or reduce the efficacy of activated charcoal, oral antidotes, or other therapies.133

Experts no longer recommend routine use of ipecac syrup in the emergency department;133 activated charcoal is preferred for the immediate treatment of most oral poisonings.a If gastric emptying indicated, consult specialized references and experts to select appropriate gastric-emptying technique.a

Do not use if risks associated with vomiting and aspiration outweigh risks associated with systemic absorption of ingested substance.146

Consult specialized references and experts for additional information about the use of ipecac syrup in the management of poisoning caused by specific agents.a (See Ingested Substances under Cautions.)

Cough

In small doses (0.3–1 mL) as an expectorant in cough preparations; however, therapeutic efficacy is doubtful.a

Eating Disorders

Misused and abused to induce vomiting following recurrent food binges in individuals with eating disorders (e.g., anorexia nervosa, bulimia nervosa).104 105 106 108 109 111 119 130 132 145 152 153 154 155 156 157 158 159 160 Efficacy may diminish with repeated use, resulting in use of increasing dosages, further systemic absorption and toxic effects.104 155 159 May result in myopathy, cardiomyopathy, and death.104 108 109 111 119 152 153 154 155 156 157 158 159 160 (See Cardiovascular Effects and also see Chronic Toxicity under Cautions.)

Factitious Disorder by Proxy

Misused by abusive parents and caregivers to intentionally produce factitious chronic illnesses in individuals under their care.130 132 135 136 137 138 139 140 141 142 143 144 161 (See Factitious Disorder by Proxy and also see Chronic Toxicity under Cautions.)

Ipecac Syrup Dosage and Administration

General

Before administering drug for acute poisoning management in a medically unsupervised setting (e.g., at home), contact a poison control center (800-222-1222), emergency medical center, or other qualified healthcare professional for advice.118 b

Administration

Oral Administration

Administer orally.a b Whenever possible, keep patients active and moving following administration.118 b

Give 200–480 mL of water or other clear liquid to adults and children >1 year of age immediately following administration of the drug to facilitate emetic action.a b In children 6 months to <1 year of age, give 120–240 mL of water or other clear liquid.b

Giving liquid prior to administration of ipecac syrup may be more successful in young and frightened children.a Gently bouncing young children may induce emetic effects earlier.a

Some experts state that clear carbonated beverages may be administered in children who will not drink water.118

Manufacturers state that ipecac syrup should not be administered with milk.b (See Specific Drugs and Foods under Interactions.)

Dosage

Pediatric Patients

Acute Poisoning
Oral

Children <6 months of age: Generally, administer under medical direction or supervision.118 b

Children 6 months to <12 months of age: May administer 5 mL;118 b however, to avoid aspiration of vomitus, obtain professional advice and guidance on proper positioning.118

Children 1 to <12 years of age: Usually, 15 mL.118 b

Children ≥12 years of age: Usually, 30 mL.118 b

If no emesis within 30 minutes, may repeat dose.118 b

If no emesis within 30 minutes of second dose, initiate measures to minimize absorption of the emetic and poison (e.g., gastric lavage, activated charcoal) to avoid toxicity from either agent.a

In a medically unsupervised setting: If no emesis within 30 minutes after administering second dose, contact a poison control center, emergency medical facility, or other qualified healthcare professional for advice.a

Adults

Acute Poisoning
Oral

Usually, 30 mL.118

If no emesis within 30 minutes, may repeat dose.118 a b

If no emesis within 30 minutes of second dose, initiate measures to minimize absorption of the emetic and poison (e.g., gastric lavage, activated charcoal) to avoid toxicity from either agent.a

In medically unsupervised setting: If no emesis within 30 minutes after administering second dose, contact a poison control center, emergency medical facility, or other qualified healthcare professional for advice.a

Cautions for Ipecac Syrup

Contraindications

  • Patient who is less than fully conscious.133 146 b

  • Severe inebriation.133 146

  • Shock.133 146

  • Seizure activity.133 146

  • Lack of gag reflex.133 146

  • Rapid (current or expected) deterioration of clinical condition.133 146

  • If ingested substance may alter mental status, compromise airway protective reflexes, or cause seizures.132 133

Warnings/Precautions

Warnings

Physical Injury

Physical injury may result from act of vomiting.132 133

GI Effects

Risk of diarrhea.132 133 154 162 163

Risk of prolonged vomiting.132 133 134 163 165 166 167 168 Rarely, prolonged vomiting associated with serious adverse effects and death in patients treated with ipecac syrup.100 115 116 117 132 133

CNS Effects

Risk of lethargy, irritability, and hyperactivity.132 133 154 162 163 168 171

Cardiovascular Effects

Risk of cardiotoxicity, principally when drug is overdosed (e.g., as fluidextract [not commercially available in the US]) or abused chronically.a

Contains a specific cardiotoxin; at high doses, may cause interstitial edema of heart muscle and necrosis of some fibers, tachycardia, T-wave depression, depressed myocardial contractility, atrial fibrillation, CHF, and myocarditis.a

Risk of hemorrhage or vascular accidents in patients with impaired cardiac function and sclerotic or other pathologic changes in blood vessels; vomiting may increase BP.132 133

Cardiotoxicity (possibly fatal) associated with chronic use105 106 107 112 120 152 154 (e.g., supraventricular tachycardia,103 104 105 106 107 119 atrial premature contractions,103 104 119 flattened or inverted T waves,103 104 105 106 119 prolonged QT and PR intervals,103 104 106 119 alterations in QRS complex,103 104 119 decreased contractility,107 119 ventricular tachycardia and fibrillation,103 104 105 cardiac arrest,103 104 105 precordial chest pain, dyspnea, hypotension, cardiac failure, pericardial effusions, and pulmonary congestion).104 105 106 107 119 120 (See Major Toxicities under Cautions and also see Eating Disorders under Uses.)

Musculoskeletal Effects

Risk of myopathy with chronic abuse (e.g., generalized weakness [especially in neck and proximal muscles of extremities], muscle aching, hyporeflexia, tenderness, stiffness, dysphagia, slurred speech, difficulty with tasks requiring muscular activity).104 106 107 109 111 114 119 (See Chronic Toxicity under Cautions and see Eating Disorders under Uses.)

Laboratory abnormalities possible with ipecac-induced myopathy (e.g., increased AST, LDH, creatine kinase, aldolase, and ALT).104 106 108 119

Sensitivity Reactions

Dermatologic Reactions

Fixed eruptions and toxic epidermal necrolysis reported rarely; however, effects not directly attributed to the drug.a

Major Toxicities

Acute Toxicity

Substantial margin of safety when administered at therapeutic dosages for emergency management of acute ingestions in patients with no contraindications to use.130 133 146 However, if emesis does not occur following administration, emetine may be absorbed and cause adverse systemic effects.a

Cases of severe toxicity usually have involved ipecac fluidextract (not commercially available in the US); 14 times more concentrated than ipecac syrup.a Volumes of ipecac fluidextract for administration are substantially smaller than those for ipecac syrup.a

Possible toxic manifestations of acute overdosage include nausea, bloody stools and vomitus, cramping and abdominal pain, hypotension, dyspnea, shock, seizures, and coma.a Heart failure is the usual cause of death following overdose.a (See Cardiovascular Effects under Cautions.)

Chronic Toxicity

Serious, potentially fatal adverse effects associated with chronic abuse in eating disorders (e.g., anorexia nervosa, bulimia nervosa); adverse effects may be secondary to complications of chronic ipecac-induced vomiting (e.g., metabolic abnormalities [e.g., hypokalemia, hypochloremia, metabolic alkalosis], dental abnormalities, esophagitis, gastric reflux, Mallory-Weiss syndrome, parotid gland enlargement, aspiration pneumonitis)102 103 or secondary to the adverse systemic effects of ipecac (e.g., skeletal and cardiac muscle cell toxicities from emetine).102 103 104 105 106 107 108 109 110 111 112 113 114 119 120 144 176

Other chronically abused drugs (e.g., cathartics, laxatives, diuretics) may also contribute to the observed spectrum of adverse effects.102 103 108

General Precautions

Possible Prescribing and Dispensing Errors

Ensure accuracy of medication; similarity in names of ipecac syrup and ipecac fluidextract may result in errors.a Ipecac fluidextract (not commercially available in the US) is 14 times more potent than ipecac syrup and inadvertent administration of ipecac fluidextract has resulted in serious toxicity and fatalities.a

Alcohol Content

Syrup contains 1–2.5% alcohol, which exceeds FDA established maximum concentration (0.5%) for nonprescription drugs intended for use in children ≤6 years of age.127 However, nonprescription containers of ipecac syrup (≤30 mL) are exempted due to small size and insignificant total alcohol content (0.75 mL).127

Alcohol and ipecac syrup usually are vomited along with other stomach contents; benefits outweigh risk of adverse effects associated with ingestion of the alcohol (0.375–0.75 mL) in the syrup.127

Ingested Substances

In a medically unsupervised setting (e.g., at home), do not administer if strychnine were ingested, turpentine, petroleum distillates, volatile oils, alkali (e.g., lye) or strong acid, or caustic or corrosive substances, unless otherwise advised by a poison control center, medical emergency facility, or other qualified healthcare professional.132 178 a b

If low-viscosity petroleum distillates (e.g., gasoline, kerosene, fuel oil, paint thinner, cleaning fluid) are ingested, many clinicians advise against the use of ipecac syrup due to the high potential for aspiration.132 133

After ingestion of liquid hydrocarbons by alert patients, the decision to induce emesis depends on the amount ingested and the relative toxicity of the particular hydrocarbon or chemical dissolved in it.a If no other contraindications, induction of emesis is indicated with benzene or hydrocarbon preparations containing camphor, pesticides, or substantial amounts of heavy metals or halogenated solvents.a

In oral antiemetic poisonings, ipecac syrup may be useful if given within 1 hour and before toxic or antiemetic effects appear.a

Use with caution after acute overdose of cardiac glycosides; may potentiate hazards of high degrees of AV block and of increased vagal activity.a (See Cardiovascular Effects under Cautions.)

Do not administer ipecac if ingested substance may alter mental status, compromise airway protective reflexes, or cause seizures.132 133 (See Contraindications under Cautions.)

Consult specialized references and experts for additional information about the use of ipecac syrup in the management of poisoning caused by specific agents.a

Concurrent Medical Conditions

Some clinicians state that ipecac syrup should not be used in debilitated patients or those with medical conditions (e.g., severe hypertension, bradycardia, hemorrhagic diathesis) that may be further compromised by induction of emesis.132 133 (See Cardiovascular Effects and also see Geriatric Use under Cautions.)

Seizures

If convulsants are ingested and patient is not having seizures, ipecac-induced vomiting and retching may precipitate seizures.a

Factitious Disorder by Proxy

Consider ipecac toxicity in the differential diagnosis in children with unexplained colitis, especially if vomiting or neuromuscular or cardiac manifestations are present.136

Unusual symptom complexes possible with chronic ipecac syrup administration (e.g., persistent or recurrent diarrhea and vomiting, muscle weakness, colitis, cardiomyopathy, fever, edema, and/or electrolyte disturbances).135 136 137 138 139 140 141 (See Chronic Toxicity under Cautions.)

Expiration Date

Periodically check expiration date; use after the expiration date may not result in emesis and is not recommended.a Only consider use in emergency situations where the expired syrup is the only emetic readily available.a

Specific Populations

Pregnancy

Category C.a

Lactation

Not known whether ipecac syrup is distributed into milk.a Use caution.a

Pediatric Use

Safety and efficacy not established for children <6 months of age in medically unsupervised setting.b

Syrup exceeds FDA established maximum alcohol concentration (0.5%) for nonprescription drugs intended for use in children ≤6 years.127 (See Alcohol Content under Cautions.)

Experts no longer recommend routinely keeping ipecac in homes with small children for emergency use.130 132 No consensus by experts on which homes might benefit from having ipecac syrup; consult individual clinicians and poison control centers for guidance.132 Evidence of efficacy in out-of-hospital settings is insufficient to support even limited use.130 132 133 134 (See Acute Poisoning under Uses.)

Geriatric Use

Some clinicians state that ipecac syrup should not be used in geriatric patients.132 133 (See Cardiovascular Effects and also see Concurrent Medical Conditions under Cautions.)

Common Adverse Effects

Diarrhea,132 133 154 162 163 lethargy,132 133 154 163 168 171 prolonged vomiting.132 133 134 163 165 166 167 168

Interactions for Ipecac Syrup

Specific Drugs and Foods

Drug or Food

Interaction

Comments

Activated charcoal

Adsorbs ipecac syrupa b

Administer ipecac first; do not give activated charcoal until vomiting completed a b

Milk

Manufacturer states do not administer with milkb

Studies suggest combination may delay the onset of emesis;125 126 however, other evidence indicates concomitant administration does not substantially reduce emetic efficacy124

Ipecac Syrup Pharmacokinetics

Absorption

Bioavailability

Limited GI absorption data; may exhibit considerable interindividual variation.a Recovery of alkaloids in vomitus ranges from 2–100% (mean 45%).101

Onset

80–85% of patients: vomiting usually occurs ≤15–30 minutes after first dose.132 150 151 162 174 If second dose required, onset usually ≤10 minutes.132 150 151 162 174

Duration

Induces an average of 3 vomiting episodes (range:1–8); average duration of each episode is 23–60 minutes.146 162 174 175

Food

Some studies suggest milk may delay onset of emesis;125 126 however, other evidence indicates concomitant administration does not substantially reduce emetic efficacy.124

Distribution

Not known whether alkaloids of ipecac are distributed into milk.a

Stability

Storage

Oral

Syrup

Tight container at <25°C.a Periodically check expiration date.a (See Expiration Date under Cautions.)

Actions

  • Emetogenic effects are the result of two major alkaloids, emetine and cephaeline; cephaeline is the more potent emetogenic agent of the two.146 173 176

  • Acts centrally by stimulating the medullary chemoreceptor trigger zone (CTZ) and locally by irritating the gastric mucosa.a Vomiting is induced by the drug only when the medullary centers are responsive.a

  • Type 3 serotonergic (5-HT3) receptors appear to mediate drug-induced nausea and vomiting.146 172

  • Produces regurgitation of contents from the stomach and upper GI tract; however, entire GI contents not regurgitated.a

Advice to Patients

  • Importance of contacting a poison control center (800-222-1222), emergency medical facility, or other qualified healthcare professional before giving ipecac.a

  • Importance of only giving to a fully conscious patient.133 146 b

  • Importance of giving additional water or other clear liquid following dose.a b

  • Importance of keeping patient active and moving.118 b

  • Advise patient to save poison container, if possible.b

  • When activated charcoal is indicated, importance of giving ipecac syrup first.a b Do not give activated charcoal until vomiting is finished.a b

  • Importance of using a preparation that has not expired.a

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.a

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.a

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Ipecac

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Syrup

70 mg (of powdered ipecac) per mL*

Ipecac Oral Solution

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions June 1, 2009. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

100. Klein-Schwartz W, Gorman RL, Oderda GM et al. Ipecac use in the elderly: the unanswered question. Ann Emerg Med. 1984; 13:1152-4. [PubMed 6150669]

101. Moran DM, Crouch DJ, Finkle BS et al. Absorption of ipecac alkaloids in emergency patients. Ann Emerg Med. 1984; 13:1100-2. [PubMed 6150666]

102. Harris RT. Bulimarexia and related serious eating disorders with medical complications. Ann Intern Med. 1983; 99:800-7. [PubMed 6360000]

103. Sansone RA. Complications of hazardous weight-loss methods. Am Fam Physician. 1984; 30:141-6. [PubMed 6147075]

104. Palmer EP, Guay AT. Reversible myopathy secondary to abuse of ipecac in patients with major eating disorders. N Engl J Med. 1985; 313:1457-9. [IDIS 207982] [PubMed 2865679]

105. Adler AG, Walinsky P, Krall RA et al. Death resulting from ipecac syrup poisoning. JAMA. 1980; 243:1927-8. [IDIS 113394] [PubMed 6102612]

106. Friedman EJ. Death from ipecac intoxication in a patient with anorexia nervosa. Am J Psychiatry. 1984; 141:702-3. [PubMed 6143508]

107. Romig RA. The potential toxicity of ipecac. Am J Psychiatry. 1984; 141:1639. [IDIS 193458] [PubMed 6150652]

108. Moldawsky RJ. Myopathy and ipecac abuse in a bulimic patient. Psychosomatics. 1985; 26:448-9. [PubMed 2859632]

109. Mateer JE, Farrell BJ, Chou SSM et al. Reversible ipecac myopathy. Arch Neurol. 1985; 42:188-90. [PubMed 2858193]

110. Mangione RA. Syrup of ipecac dangers. Am Pharm. 1985; NS25:716-7.

111. Bennett HS, Spiro AJ, Pollack MA et al. Ipecac-induced myopathy simulating dermatomyositis. Neurology. 1982; 32:91-4. [IDIS 143601] [PubMed 6119651]

112. Romig RA. Anorexia nervosa, ipecac, and sudden death. Ann Intern Med. 1985; 103:641-2. [IDIS 205114] [PubMed 2864012]

113. Hull BL. Ipecac on prescription? Am J Psychiatry. 1985; 142:141. Letter.

114. Pope HG Jr, Hudson JI, Nixon RA et al. The epidemiology of ipecac abuse. N Engl J Med. 1986; 314:245-6. [IDIS 209577] [PubMed 2867469]

115. Wolowodiuk OJ, McMicken DB, O’Brien P. Pneumomediastinum and retropneumoperitoneum: an unusual complication of syrup-of-ipecac-induced emesis. Ann Emerg Med. 1984; 13:1148-51. [PubMed 6150668]

116. Timberlake GA. Ipecac as a cause of the Mallory-Weiss syndrome. South Med J. 1984; 77:804-5. [IDIS 186540] [PubMed 6145220]

117. Tandberg D, Liechty EJ, Fishbein D. Mallory-Weiss syndrome: an unusual complication of ipecac-induced emesis. Ann Emerg Med. 1981; 10:521-3. [PubMed 6116471]

118. US Food and Drug Administration. Poison treatment drug products for over-the-counter human use; tentative final monograph. [Docket No 81N-0050]. Fed Regist. 1985; 50:2244-62.

119. Brotman MC, Forbath N, Garfinkel PE. Myopathy due to ipecac syrup poisoning in a patient with anorexia nervosa. Can Med Assoc J. 1981:125: 453-4.

120. Gosselin RE, Smith RP, Hodge HC. Clinical toxicology of commercial products. 5th ed. Baltimore: Williams & Wilkins; 1984:III-214-7.

121. Grbcich PA, Lacouture PG, Kresel JJ et al. Expired ipecac syrup efficacy. Pediatrics. 1986; 78:1085-9. [IDIS 224419] [PubMed 2878409]

122. Huff MR, Manske TA, Forsyth C et al. Watch out for “old” ipecac. Pediatrics. 1984; 73:569. [PubMed 6143294]

123. Hornfelt CS, Rogers AA. Efficacy of expired syrup of ipecac. Vet Hum Toxicol. 1984; 26:319. [PubMed 6147042]

124. Grbcich PA, Lacouture PG, Lewander WJ et al. Effect of milk on ipecac-induced emesis. J Pediatr. 1987; 110:973-5. [IDIS 230453] [PubMed 2884284]

125. Varipapa R, Oderda J. Effect of milk on ipecac induced emesis. N Engl J Med. 1977; 296:112-3.

126. Varipapa R, Oderda G. Effect on milk on ipecac induced emesis. J Am Pharm Assoc. 1977; 17:510. [PubMed 19520]

127. Food and Drug Administration. Over-the-counter drug products intended for oral ingestion that contain alcohol; amendment of final rule. 21 CFR Part 328. Final rule. [Docket No. 95N-0341] Fed Regist. 1996; 61:68629-30.

128. American Academy of Pediatrics. Policy Statement. Office-Based Counseling for Injury Prevention (RE9427). Available at: http://www.aap.ort/policy/00410.html. Accessed 2003 Nov 6.

129. American Academy of Pediatrics. Committee on Drugs. Drugs for Pediatric Emergencies. Vol. 101 No. 1 January 1998. Available at: http://www.pediatrics.org/cgi/content/full/101/1/e13.

130. American Academy of Pediatrics. Committee on Injury, Violence, and Posion Prevention. Policy Statement. Poison Treatment in the Home. Pediatrics. 2003; 112(5): 1182-85. [PubMed 14595067]

131. American Association of Poison Control Centers (AAPCC). Poison Prevention Tips to Keep Our Children Safe. Available at http://www.aapcc.org/children.htm.

132. Manoguerra,AS, Cobaugh, DJ and the Members of the Guidelines for the Management of Poisonings Consensus Panel for the American Association of Poison Control Centers. Guideline on the Use of Ipecac Syrup in the Out-of-Hospital Management of Ingested Poisons. [2004]. From AAPCC website (). Accessed 2004 Sep 21.

133. The American Academy of Clinical Toxicology. Poison Statements: Ipecac Syrup. Available at: http://www.clintox.org/Pos_Statements/Ipecac.html. Accessed 2003 Nov 4.

134. Bond GR. Home Syrup of Ipecac Use Does Not Reduce Emergency Department Use or Improve Outcome. Pediatrics. 2003; 112 (5): 1161-64.

135. McClung HJ, Murray R, Braden NJ et al. Intentional ipecac poisoning in children. Am J Dis Child. 1988; 142:637-9. [IDIS 242261] [PubMed 2897158]

136. Johnson JE, Carpenter BL, Benton J et al. Hemorrhagic colitis and pseudomelanosis coli in ipecac ingestion by proxy. J Pediatr Gastroenterol Nutr. 1991; 12:501-6. [IDIS 284185] [PubMed 1678009]

137. Sutphen JL, Saulsbury FT. Intentional ipecac poisoning: Munchausen syndrome by proxy. Pediatrics. 1988; 82:453-6. [IDIS 245565] [PubMed 2900492]

138. Colletti RB, Wasserman RC. Recurrent infantile vomiting due to intentional ipecac poisoning. J Pediatr Gastroenterol Nutr. 1989; 8:394-6. [IDIS 252826] [PubMed 2565382]

139. Berkner P, Kastner T, Skolnick L. Chronic ipecac poisoning in infancy: a case report. Pediatrics. 1988; 82:384-6. [IDIS 245733] [PubMed 2900491]

140. Day L, Kelly C, Reed G et al. Fatal cardiomyopathy: suspected child abuse by chronic ipecac administration. Vet Hum Toxicol. 1989; 31:255-7. [PubMed 2568029]

141. Santangelo WC, Richey JE, Rivera L et al. Surreptitious ipecac administration simulating intestinal pseudo-obstruction. Ann Intern Med. 1989; 110:1031-2. [IDIS 255909] [PubMed 2567141]

142. Goebel J, Gremse DA, Artman M. Cardiomyopathy from ipecac administration in Munchausen syndrome by proxy. Pediatrics. 1993; 92:601-3. [IDIS 320554] [PubMed 8105444]

143. Schneider DJ, Perez A, Knilans TE et al. Clinical and pathological aspects of cardiomyopathy from ipecac administration in Munchausen’s syndrome by proxy. Pediatrics. 1996; 97:902-6. [IDIS 368237] [PubMed 8657536]

144. Perrone J. Dieting agents and regimens. In: Goldfrank LR, Howland MA, Flomenbaum NE et al, eds. Goldfrank’s toxicologic emergencies. 7th ed. New York: McGraw Hill; 2002:571-4.

145. Robertson WO. Safety of ipecac syrup. JAMA. 1980; 244:1675. [IDIS 125459] [PubMed 6106075]

146. Howland MA. Syrup of ipecac. In: Goldfrank LR, Howland MA, Flomenbaum NE et al, eds. Goldfrank’s toxicologic emergencies. 7th ed. New York: McGraw Hill; 2002: 465-8.

147. Food and Drug Administration Center for Drug Evaluation and Research. Meeting of the Nonprescription Drugs Advisory Committee, 8:07 a.m Thursday, June 12, 2003. From FDA website . Accessed 9/29/04.

148. Meadows M. A primer on summer safety. FDA Consumer. US Food and Drug Administration. 2004; May-June:18–25.

149. Cincinnati Children’s Hospital Medical Center. Drug and Poison Information Center. Syrup of ipecac no longer recommended. Available at . Accessed 2004 Sep 28.

150. Krenzelok EP, Dean BS. Syrup of ipecac in children less than one year of age. J Toxicol Clin Toxicol. 1985; 23:171-6. [IDIS 208201] [PubMed 2865374]

151. Ilett KF, Gibb SM, Unsworth RW. Syrup of ipecacuanha as an emetic in adults. Med J Aust. 1977; 2:91-3. [PubMed 19691]

152. Dawson JA, Yager JA. A case of abuse of syrup of ipecac resulting in death. J Am Coll Health. 1986; 34:280-2. [PubMed 2875087]

153. Rosenberg NL, Ringel SP. Myopathy from surreptitious ipecac ingestion. West J Med. 1986; 145: 386-8. [IDIS 220957] [PubMed 2876555]

154. 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. [IDIS 220416] [PubMed 2875430]

155. Friedman AG, Seime RJ, Roberts T et al. Ipecac abuse: a serious complication in bulimia. Gen Hosp Psychiatry. 1987; 9:225-8. [PubMed 2884167]

156. Halbig L, Gutmann L, Goebel HH et al. Ultrastructural pathology in emetine-induced myopathy. Acta Neuropathol. (Berl). 1988; 75:577-82.

157. Kuntzer T, Bogousslavsky J, Deruaz JP et al. Reversible emetine-induced myopathy with ecg abnormalities: a toxic myopathy. J Neurol. 1989; 236:246-8. [PubMed 2760638]

158. Dresser LP, Massey EW, Johnson EE et al. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatry. 1992; 56:560-2.

159. Thyagarajan D, Day BJ, Wodak J et al. Emetine myopathy in a patient with an eating disorder. Med J Aust. 1993; 159: 757-60. [IDIS 326394] [PubMed 8264462]

160. Ho PC, Dweik R, Cohen MC. Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion. Clin Cardiol. 1998; 21:780-3. [PubMed 9789704]

161. Cooper C, Kilham H, Ryan M. Ipecac--a substance of abuse. Med J Aust. 1998; 168:94-5. [IDIS 400346] [PubMed 9469196]

162. Litovitz TL, Klein-Schwartz W, Oderda GM et al. Ipecac administration in children younger than 1 year of age. Pediatrics. 1985; 76:761-4. [IDIS 209480] [PubMed 2865716]

163. Wrenn K, Rodewald L, Dockstader L. Potential misuse of ipecac. Ann Emerg Med. 1993; 22:1408-12. [PubMed 8103307]

164. Wax PM, Caobaugh DJ, Lawrence RA. Should home ipecac-induced emesis be routinely recommended in the managment of toxic berry ingestions? Vet Hum Toxicol. 1999; 41:394-7.

165. Veltri JC, Temple AR. Telephone management of poisonings using syrup of ipecac. Clin Toxicol. 1976; 9:407-17. [PubMed 8236]

166. Saincher A, Sitar DS, Tenenbein M. Efficacy of ipecac during the first hour after drug ingestion in human volunteers. J Toxicol Clin Toxicol. 1997; 35: 609-15.

167. McNamara RM, Aaron CK, Gemborys M et al. Efficacy of charcoal cathartic versus ipecac in reducing serum acetaminophen in a simulated overdose. Ann Emerg Med. 1989; 18: 934-8 [PubMed 2569851]

168. Czajka PA, Russell SL. Nonemetic effects of ipecac syrup. Pediatrics. 1985, 75:1101-4.

169. Knight KM, Doucet HJ. Gastric rupture and death caused by ipecac syrup. South Med J. 1987; 80: 786-7. [IDIS 230855] [PubMed 2884730]

170. Robertson WO. Syrup of ipecac associated fatality: a case report. Vet Hum Toxicol. 1979; 21: 87-9.

171. Chafee-Bahamon C, Lacouture PG, Lovejoy FH. Risk assessment of ipecac in the home. Pediatrics. 1985; 75:1105-9. [IDIS 2000190] [PubMed 2860633]

172. Forster ER, Palmer JL, Bedding AW et al. Syrup of Ipecacuanha-induced nausea and emesis is mediated by 5HT3 receptors in man. J Physiol. (London). 1994; 477:72.

173. Stewart J. Effects of emetic and cathartic agents on the gastrointestinal tract and the treatment of toxic ingestion. J Toxicol Clin Toxicol. 1983; 20:199-253. [IDIS 177474] [PubMed 6137573]

174. MacLean W. A comparison of ipecac syrup and apomorphine in the immediate treatment of igestion of poisons. J Pediatr. 1973; 82:121-4. [IDIS 30570] [PubMed 4404603]

175. Rauber A, Maroncelli R. The duration of emetic effects of ipecac: Duration and frequency of vomiting. Vet Hum Toxicol. 1982; 24:281.

176. Manno B, Manno JE. Toxicology of ipecac. Clin Toxicol. 1977; 10:221-42. [PubMed 15766]

177. Watson WA, Litovitz TL, Klein-Schwartz W et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Available at AAPCC website (). Accessed 2004 Dec 7.

178. Smilkstein MJ. Techniques used to prevent gastrointestinal absorption of toxic compounds. In: Goldfrank LR, Howland MA, Flomenbaum NE et al, eds. Goldfrank’s toxicologic emergencies. 7th ed. New York: McGraw Hill; 2002: 44-57.

179. Bond CR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: A state-of-the-art review. Ann Emerg Med. 2002; 39:273-86. [IDIS 478717] [PubMed 11867980]

180. Sweetman SC, ed. Martindale: the complete drug reference. 33rd ed. London: The Pharmaceutical Press; 2002:1000-1.

181. Ellenhorn MJ, ed. Ellenhorn’s Medical Toxicology. 2nd ed. Baltimore, MD: Williams & Wilkins; 1997: 66-78.

182. Shannon M. Ingestion of toxic substances by children. N Engl J Med. 2000; 342:186-91. [IDIS 439237] [PubMed 10639545]

183. Ahya SN, Flood K, Paranjothi S, eds. Washington Manual of Medical Therapeutics. 30th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001: 544-73.

184. Henry JA, Hoffman JR. Continuing controversy on gut decontamination. Lancet. 1998; 352:420-1. [IDIS 415080] [PubMed 9708747]

185. Burns MM. Activated charcoal as the sole intervention for treatment after childhood poisoning. Curr Opin Pediatr. 2000; 12:166-71. [PubMed 10763768]

a. AHFS drug information 2008. McEvoy GK, ed. Ipecac syrup. Bethesda, MD: American Society of Health-System Pharmacists; 2008:2987-90.

b. Humco. Ipecac oral solution USP product information. Texarkana, TX; 2006 Jan.

Hide
(web1)