ipecac syrup

Available forms
Available with and without a prescription
Syrup: 70 mg powdered ipecac/ml

Indications and dosages
 To induce vomiting in poisoning. Adults and children age 12 and older: 15 to 30 ml P.O., followed by 200 to 300 ml of water.
Children ages 1 to 11: 15 ml P.O., followed by about 200 ml of water.
Children younger than age 1: 5 to 10 ml P.O., followed by 100 to 200 ml of water. May repeat dose once after 20 minutes, if needed.

Pharmacodynamics
Emetic action: Ipecac syrup directly irritates the GI mucosa and directly stimulates the chemoreceptor trigger zone through the effects of emetine and cephalin, its two alkaloids.

Pharmacokinetics
Absorption: Absorbed in significant amounts mainly when it doesn’t produce emesis.
Distribution: No information available.
Metabolism: No information available.
Excretion: Emetine is excreted in urine slowly, over a period lasting up to 60 days.

Contraindications and precautions
Contraindicated in semicomatose or unconscious patients or those with severe inebriation, seizures, shock, or loss of gag reflex. Don’t give after ingestion of gasoline, kerosene, volatile oils, or caustic substances (lye). Use with caution in patients with CV disease and in bulimics.

Interactions
Drug-drug. Activated charcoal: May inactivate ipecac syrup and shouldn’t be taken together. Activated charcoal may be given after patient vomits.
Antiemetics: Decreases effectiveness of ipecac. Avoid use together.
Phenothiazines: Chlorpromazine has been associated with severe dystonic reactions. Monitor patient carefully, and avoid use if possible.
Drug-food. Carbonated beverages: May cause abdominal distention. Tell patient to avoid use together.
Milk (or milk products): May decrease therapeutic effectiveness of ipecac syrup. Tell patient to avoid use together.
Vegetable oil: Delays absorption. Tell patient not to take together.

Adverse reactions
CNS: depression, drowsiness.
CV: arrhythmias, bradycardia, hypotension; atrial fibrillation, myocarditis (with excessive doses).
GI: diarrhea.

Effects on lab test results
None reported.

Overdose and treatment
Effects of overdose include diarrhea, persistent nausea or vomiting (longer than 30 minutes), stomach cramps or pain, arrhythmias, hypotension, myocarditis, difficulty breathing, and unusual fatigue or weakness. Toxicity from chronic ipecac overdose usually involves use of the concentrated fluid extract in dosage appropriate for the syrup. Effects of cardiotoxicity include tachycardia, T-wave depression, atrial fibrillation, depressed myocardial contractility, heart failure, and myocarditis. Other toxic effects include bloody stools and vomitus, hypotension, shock, seizures, and coma. Heart failure is the usual cause of death.
 Treatment requires discontinuation of drug followed by symptomatic and supportive care, which may include digitalis and pacemaker therapy to treat cardiotoxic effects. However, no antidote exists for the cardiotoxic effects of ipecac, which may be fatal despite intensive treatment.

Special considerations
• Ipecac syrup empties the stomach completely within 30 minutes in over 90% of patients; average emptying time is 20 minutes.
 ALERT Don’t confuse ipecac syrup with ipecac fluid extract, which is rarely used but which is 14 times more potent. Never store these two drugs together-the wrong drug could cause death.
• In antiemetic toxicity, ipecac syrup is usually effective if less than 1 hour has passed since ingestion of antiemetic.
• Ipecac syrup may be used in small amounts as an expectorant in cough preparations; however, this use has doubtful therapeutic benefit.
• Drug may be abused by patients with eating disorders such as bulimia or anorexia nervosa.
Breast-feeding patients
• Safety in breast-feeding women hasn’t been established; possible risks to infant must be weighed against benefits of drug.
Pediatric patients
• Advise parents to keep ipecac syrup at home at all times but to keep it out of children’s reach and to call poison control center before using.

Patient education
• Instruct patient to take syrup with 1 or 2 glasses of water.
• Advise patient to take activated charcoal only after vomiting has stopped.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use