The role of syrup of ipecac has changed dramatically over the past decade. Once the mainstay of poison management, a critical evaluation of animal, volunteer, and a limited number of clinical studies suggests that ipecac administration should be reserved for a very few rare circumstances, if any, rather than administered on a routine basis.3,5,32 The rationale for this change is based on the facts that (1) most poisonings in children are benign; (2) many adults overdose with xenobiotics that rapidly cause an altered mental status, which constitutes a contraindication to the administration of ipecac; (3) ipecac-induced vomiting may be delayed or persistent, thereby resulting in a delay in the administration of activated charcoal; and (4) the abuse of ipecac by bulimics is substantial.54
Syrup of ipecac is an emetic that has been used for the management of poisonings since the 1950s and has been available without prescription since the late 1960s. Pediatricians were encouraged to advise parents to keep syrup of ipecac in their homes. Many physicians currently believe that there is no role for syrup of ipecac in the prehospital or hospital setting and that the abuse of syrup of ipecac by patients with bulimia outweighs any benefit originating from keeping syrup of ipecac as a nonprescription drug. The Food and Drug Administration (FDA) is still reviewing whether to make syrup of ipecac available only by prescription. Advocates for maintaining the nonprescription status of syrup of ipecac support home stocking of ipecac for use in remote areas and limiting use in healthcare facilities to those rare instances when activated charcoal, orogastric lavage, or whole-bowel irrigation with polyethylene glycol electrolyte lavage solution may be inappropriate or inadequate. Changing the availability of syrup of ipecac to prescription status only could result in the complete disappearance of syrup of ipecac from the pharmaceutical market if the FDA requires a new drug application.51 Under these circumstances, it might not be profitable for any drug company to invest in a new drug application.
Ipecac is derived from the dried rhizome and roots of plants found in Brazil belonging to the family Rubiaceae, such as Cephaelis acuminata and Cephaelis ipecacuanha.59,60 Cephaeline and emetine are the two alkaloids largely responsible for the production of nausea and vomiting, with cephaeline being the more potent.31 Each 15-mL dose of syrup of ipecac contains 16 to 21 mg of cephaeline and 6.4 to 21 mg of emetine, resulting in variable cephaeline-to-emetine ratios. Syrup of ipecac also contains a small amount of psychotrine, which does not contribute to emesis but is currently under investigation for its potential anti-HIV effects.
After 20 or 30 mL of syrup of ipecac was administered to human volunteers plasma, vomitus, and urine concentrations of emetine and cephaeline were determined by the use of high-performance liquid chromatography (HPLC).50,65 Peak plasma concentrations of the alkaloids were reached by 20 minutes ...