Ipecac

Article Author:
Thomas Benzoni
Article Editor:
William Gossman
Updated:
10/27/2018 12:31:40 PM
PubMed Link:
Ipecac

Indications

Ipecac is a medication once used to induce vomiting. Its medical use has virtually vanished; its abuse is increasing as a purgative in eating disorders. 

Ipecac is commonly made from alcohol extraction of Carapichea ipecacuanha. This extract is often mixed with glycerin, sugar (syrup), and methylparaben. The active ingredients are plant alkaloids, cephaeline, and methyl-cephaeline (emetine).

Paradoxically, ipecac is itself a poison. Because it promptly induces vomiting, there is little concern for its intrinsically poisonous nature.

Emetine, a component of ipecac, has been found to have antihelminthic and antiamoebic properties.

Mechanism of Action

Ipecac irritates the stomach lining and chemically stimulates the CRTZ (ChemoReceptor Trigger Zone) to induce near-immediate vomiting. For some years, this was the justification for its recommendation for administering in the case of orally ingested poisons. However, clinical research began to call this into question.

Beginning with the 1997 position statement by the American Academy of Clinical Toxicology position statement on ipecac syrup in poisonings, ipecac had fewer uses. "Syrup of ipecac should not be administered routinely in the management of poisoned patients. 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." (from the abstract: American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. Position Statement: Ipecac Syrup (J Toxicol Clin Toxicol 1997 ; 35 : 699 – 709).

The 2013 position paper update on ipecac syrup for gastrointestinal decontamination gave no more encouragement: "... there remains no convincing evidence from clinical studies that ipecac improves the outcome of poisoned patients. Furthermore, the availability of ipecac is rapidly diminishing. Conclusions. The routine administration of ipecac at the site of ingestion or in the emergency department should be avoided. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. There is not sufficient evidence to warrant any change in the previous Ipecac position papers. There are, however, insufficient data to support or exclude ipecac administration soon after ingestion of some specific poisons in rare situations." from the Abstract: (http://www.clintox.org/wp-content/uploads/2016/04/Position-Statement-Ipecac-Syrup-1.pdf).

The ending statement has caused some consternation; it is intended to mean that the practitioner may be practicing good medicine if she believes ipecac may help decrease the burden of ingestion by administering it very soon after ingestion.

In a different realm, ipecac and its derivatives inhibit protein synthesis. Its components have found some use as antimicrobials with activity against amoebas and helminths. For this use, however, it is administered parenterally (injection).

Administration

When it first came out, ipecac was approved for a 1 oz dose without prescription for the initial home treatment of poisoning. This was the position of the American Academy of Pediatrics, American Associations of Poison Control Centers, American Medical Association, and the FDA's medical advisory board as a method to induce vomiting "for quick first-aid use in the home, under medical supervision" for use in cases of accidental overdose or poisoning. (sourced from Wiki, "Syrup of Ipecac" accessed July 2, 2107.)

Parade magazine Jan 9, 1966, issue noted Ipecac was "highly effective (https://news.google.com/newspapers?id=3wUrAAAAIBAJ&sjid=GJgFAAAAIBAJ&pg=4879%2C4587550.) By 2007, it was recommended Ipecac be thrown out of the home medicine chest (http://pediatrics.aappublications.org/content/119/1/202) (sourced from Wiki, above)

Ipecac isn't given any more for medical reasons; it used to be dosed 15 cc of a 1/14 preparation.

Adverse Effects

Ipecac induces vomiting with all its attendant problems, including delays in the administration of gastrointestinal (GI) medication. This leads to delays in activated charcoal, amongst others. Prolonged vomiting is uncomfortable and can lead to electrolyte disorders. Additionally, it doesn't do a good job of gastric emptying.

Emetine blocks the 40-S ribosomal unit causing a decrease in protein production. This inhibition of protein synthesis is a feature shared with several classes of antibiotics (macrolides).

Contraindications

Ipecac, if used with a caustic ingestion, causes a return: if it burned going down, it burns coming up. It should not be used when a patent airway is not assured for the entire duration of action, one to two hours. In general, if signs of absorption and toxicity are demonstrated, the administration is likely to be futile, ensuring risk (chance) of harm without risk of benefit.

As ipecac interferes with protein generation and may aggravate myopathy, it should be used with caution in patients with muscular function disorders. 

Monitoring

Ipecac is rarely useful for most poisonings. It is unsuccessful at removing any great quantities of ingested poisons unless delivered in the first few minutes post ingestion; even then, the result is variable and rather poor (see the mechanism of action). Its effect of uncontrolled vomiting delays other gastrically administered antidotes (e.g., activated charcoal) by one to two hours. A controlled airway is a must. If the patient demonstrates signs of toxicity that include sedation or an inability to maintain their airway, ipecac will not only create a risk of aspiration of vomited material, it will almost certainly be ineffectual as the drug is already absorbed (as demonstrated by neurologic suppression).

If it has been used recreationally, see section on nausea and vomiting.

Toxicity

Ipecac appears to have little innate toxicity. "Considering that over 3 million patients received therapeutic doses of ipecac during the 14-year period of 1983 through 1996, ipecac appears to have a high margin of safety. The potential complications of the therapeutic use of ipecac are well-documented, but serious sequelae occur rarely. An important concern is that the use of ipecac can delay the administration of activated charcoal by one to two hours." (p. 5, 2103 AACT position statement, above.)

Ipecac has very little accepted medical use in toxicology. If administered in the first few minutes after an oral ingestion of a non-corrosive, nonvolatile substance which, if absorbed and metabolized, may cause harm, Ipecac may remove an uncertain amount of the ingested by vomiting it up. The amount removed is very uncertain.

(Author's note: the AACT position paper referenced herein is a worthy read. The Academy reviews the literature in depth, including frequent patient vignettes.)