Scientific Name(s): C. acuminata H. Karst (Cartagena ipecac)., Cephalelis ipecacuanha A. Rich. (Rio Ipecac).
Common Name(s): Costa Rica ipecac, Golden root, Ipecac, Ipecacuanha, Matto Grosso ipecac, Rio or Brazilian ipecac
Also known as Psychotria ipecacuanha, ipecac is a small perennial tropical plant that grows to about 60 cm in height. Horizontal roots extend from its slender underground stem. At maturity, the roots have a dark brown or red covering, a bitter taste, and a musty odor. The plant is native to the humid forests of Bolivia and Brazil where large plantations have been established to commercialize the collection of ipecac root. Much of the root crop continues to be harvested from the wild, particularly in South America.1 India also is an important producer of ipecac.
Brazilian Indians valued ipecac as a remedy for dysentery and this information was brought to Europe by Portuguese missionaries.2, 3 It was used by the physician Jean Helvetius in 1686 to cure the son of Louis XIV of amebic dysentery.3 It remained a secret remedy until Helvetius sold it to the French government, which in 1688 subsequently disclosed that the composition of the dysentery remedy contained a large amount of ipecacuanha.3 The French chemist Pierre Joseph Pelletier extracted the alkaloid substance from the ipecacuanha in 1817 and named it emetine, believing the mixed alkaloids to be 1 compound. Two English chemists, Paul and Cownley, later demonstrated in 1894 that there were actually 2 distinct alkaloids, emetine and cephaeline.3 The dried root and rhizome are the sources of the medicinal products. Ipecac has been widely used in its syrup form as a potent and effective emetic. Ipecac powder has been used to induce sweating at the onset of influenza, and small amounts of the extract have been incorporated into cough syrups as expectorants. Emetine, derived from the root, has been used for more than a century to treat dysentery.4 In October 1965, the Food and Drug Administration ruled that 30 mL (1 oz) bottles of ipecac syrup could be dispensed without a prescription. Ipecac syrup is part of public health strategies for childhood poisoning prevention, but it no longer is routinely recommended.3
The root and rhizomes of ipecac contain a number of closely related isoquinoline alkaloids in a total concentration of up to 2.5% by weight of the root, primarily emetine, cephaeline, and psychotrine.4 Because leaves contain less than 0.5% emetine, they are usually not processed commercially. More than a half dozen other alkaloids are found in different parts of the plant. Emetine may be manufactured commercially by the chemical modification of either cephaeline or psychotrine.
Uses and Pharmacology
Ipecac alkaloids are rapidly absorbed and quickly enter the systemic circulation.5 Response will vary among patients depending on the amount and identity of ingested material, as well as other clinical factors. One study has shown variations in the absorption patterns of ipecac syrup in a number of subjects. There is extensive distribution throughout the body and little of either alkaloid appears in the urine within 3 hours of administration.6 The main excretion route for ipecac alkaloids is biliary.7 It has been shown in 1 study that ipecac alkaloids may be detectable in urine several weeks after ingestion.8 These findings have important implications for the investigation of ipecac syrup abuse and the identification of Munchausen syndrome by proxy or eating disorders using ipecac syrup.6, 8
The focus of present studies is the emetic potential of ipecac syrup, but there are limitations to these studies. They often are small and it is difficult to extrapolate data from simulated overdoses in volunteers who are using nontoxic amounts to overdose patients who are ingesting large toxic doses; dissolution, absorption, and gastric emptying rates are affected by the amount ingested. Also, overdose patients may take multiple drugs or other substances, and individual patient characteristics affect the outcome. Each situation must be individually assessed to determine if ipecac syrup is appropriate, dependent on substance ingested, time since ingestion, and clinical status of the patient.
Emetine's primary central action is on the chemoreceptor trigger zone. Various mechanisms for emesis by ipecac have been proposed.8 One study suggested an important role for 5-HT3 receptors, as well as ipecac's high affinity for 5-HT4 receptors. Cephaeline is about twice as potent as emetine in causing emesis.9
Debate surrounds the use of ipecac and which patients will most benefit from it compared with other available treatments.3, 10 Though 1 study found no apparent benefit in patient outcome when syrup of ipecac was used in the home, there may be a benefit in certain poisonings. This remains to be proven.11
Administer ipecac should to an alert, conscious patient who has ingested a potentially toxic amount of a poison.12 Do not administer ipecac to a patient who has ingested either a corrosive substance or hydrocarbon with a high aspiration potential (eg, gasoline).12
Maximum benefit can be expected in those patients who present soon after poison ingestion.3, 10 A 2004 ipecac syrup position paper recommends that it only be administered within 60 minutes of ingesting poison.12
There are limited studies in animals, but it was found that the amount of ingested material removed by ipecac-induced emesis depended on the time elapsed between the dosing and the onset of emesis.12 There are limitations to the extrapolation of data from animal studies to the human model.3
Ipecac syrup induces vomiting in 15 to 60 minutes and is most effective when accompanied by fluid intake.13 It has been shown that the recovery of ingested substance is highly variable and decreases over time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients. There are insufficient data to either support or exclude ipecac administration soon after poison ingestion.12
Both cephaeline and emetine are active amebicides, although emetine is more active. Emetine inhibits cell protein synthesis.13
Research reveals no data regarding the use of ipecac as an amebicide in animals.
Emetine injected intramuscularly is distributed systemically. Emetine kills motile trophozoites of Entamoeba histolytica in doses smaller than those effective against cysts.13 The drug does not reach high levels in the gut and therefore is not effective against amebic dysentery. It is useful for amebic abscesses and hepatitis.
Ipecac is not currently recommended as an emetic for childhood poisonings. Activated charcoal now is the treatment of choice. Always refer to a health care professional or poison control center when an accidental poisoning occurs. Do not confuse the syrup with the fluid extract of ipecac, which is 14 times stronger.14 Ipecac syrup, which contains total alkaloids 123 to 157 mg per 100 mL, has been used to induce vomiting. The usual dose range for the syrup is 10 to 30 mL, yielding a dose of alkaloids 12 to 48 mg. Follow ipecac administration in adults with 240 mL of water and 120 to 240 mL of water in children. The dose may be repeated if emesis does not occur in 20 to 30 minutes. For children 6 to 12 months of age, ipecac 5 to 10 mL with 120 to 240 mL of water usually is a sufficient dose.12 In patients younger than 6 months of age, administer ipecac syrup only under physician supervision. Cumulative toxicity requires administration of emetine for amebic dysentery in low doses for short periods of time with intervals of several weeks between treatments.
Pregnancy / Lactation
Documented adverse effects include uterine stimulation.15 Avoid use.
None well documented.
Powdered ipecac is a respiratory irritant. Pharmacists may develop rhinitis or asthma following repeated exposure to the powder during compounding procedures. Emetine can irritate skin if applied topically.4 The most common complications of ipecac syrup are diarrhea, lethargy, drowsiness, and prolonged vomiting.10, 12 More severe complications include gastric rupture and Mallory-Weiss syndrome.3
Ipecac extracts can be highly toxic when given either acutely or chronically.4 Cephaeline is more toxic than emetine, causing more nausea and vomiting. Emetine, which constitutes more than half of the total ipecac content, has been associated with serious cardiotoxicity.16, 17 If given for a prolonged period of time or in total doses exceeding 1 g, emetine cause myositis at the injection site, GI and nervous system symptoms, hematuria, and circulatory collapse. Therefore, to treat amebic dysentery, emetine is given in low doses for a short period of time with several weeks between treatment regimens. The synthetic compound 2,3-dihydroemetine often is used to treat amebiasis. It may lead to less cardiotoxicity, but may be less effective than emetine.4, 13
Ipecac cardiomyopathy may be reversible, but it is unclear at which point the damage to myocardium is reversible. Further study is needed.16 In animal studies, emetine has been shown to cause cardiac toxicity. A high level of emetine was evident in the heart.7 One case of ipecac abuse demonstrated reversible left ventricular dysfunction over a 10-day period. Another case described a woman who ingested ipecac syrup 200 mL/wk for 3 months who developed myopathy, which resolved 4 months after stopping ipecac use.16, 18 This myopathy may be accompanied by cardiomyopathy.19
Fluid extract of ipecac largely is not used because of the high number of fatal overdoses that occurred when the product was mistaken for syrup of ipecac. The fluid extract is 14 times more concentrated than the syrup. As little as 10 mL may be fatal.17 The United States Pharmacopeia has not listed ipecac fluid extract since 1970, and it is unavailable commercially.3, 8 By comparison, syrup of ipecac has been used as a first-aid emetic. As much as 105 mL of the syrup has been retained in a child with only minor changes in the ECG. At least 1 fatality has been reported with the syrup in a 26-year-old woman who ingested 3 to 4 bottles of the syrup each night over a 3-month period.20
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