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 risk^{130 132 133} (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

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 use^{105 106 107 112 120 152 154} (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.)

ActionsActions

• 
  

  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

  
  


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  Importance of only giving to a fully conscious patient.^{133 146 b}

  
  


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  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

  
  


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  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

Disclaimer

This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.

The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.

AHFS Drug Information. © Copyright, 1959-2011, Selected Revisions June 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

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