Syrup of ipecac

Syrup of ipecac(/ˈɪpɪkæk/), or simplyipecac, is a drug that was once widely used as anexpectorant(in low doses) and a rapid-actingemetic(in higher doses). It is obtained from the driedrhizomeandrootsof the ipecacuanha plant (Carapichea ipecacuanha), from which it derives its name. It is no longer regularly used in medicine.
In particular, the rapidly inducedforceful vomitingproduced by ipecac was considered for many years to be an importantfront-linetreatment for orally ingestedpoisons. However, subsequent studies (including a comprehensive 2005meta-study) revealed the stomach purging produced by ipecac to be far less effective at lowering total body poison concentrations than theadsorptioneffect of oralactivated charcoal(which is effective through the entire gastrointestinal tract and is often coupled withwhole bowel irrigation). Ipecac also presents a small risk ofoverdose(being a mild poison itself) and a major risk ofesophagitisandaspiration pneumoniaif used to purgecorrosivepoisons. Having long been replaced (even in the emetic role) by more effective medications, theAmerican Society of Health-System Pharmacists(ASHP) now advises that "Ipecac syrup is no longer recommended for routine management of outpatient ingestions of medications or other chemicals."
Ipecac is commonly made from alcohol extraction of the ipecacuanha plant. The extract is commonly mixed with glycerin, sugar (syrup), and methylparaben. The active ingredients are plant alkaloids, cephaeline, and methyl-cephaeline (emetine).
Ipecac was used in cough mixtures as anexpectorantor anemeticfrom the 18th until the early 20th century.For instance, ipecac andopiumwere used to produceDover's powder, which was used in syrup form.
In 1965, theFood and Drug Administration(FDA) approved the sale of up to one ounce of syrup of ipecac without a prescription. At the time it was approved, its use was recommended by theAmerican Academy of Pediatrics,American Association 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 accidentalpoisoning.
Current guidelines from theAmerican Academy of Pediatrics, however, strongly advise against this and in fact recommend the disposal of any syrup of ipecac present in the home.Many toxicological associations have also issued position papers recommending against its use as a first-line treatment for most ingested poisons,because of a lack of evidence that syrup of ipecac actually helps improve the outcome in cases of poisoning. Moreover, accidental overdose of ipecac can result when administered in the home.When dealing with poisoning cases in the hospital, it became difficult to obtain adifferential diagnosiswhen syrup of ipecac had been administered, as this can add further symptoms.
A 2005 review by aHealth Resources and Services Administration-funded scientific panel concluded that vomiting alone does not reliably remove poisons from thestomach. The study suggested that indications for use of ipecac syrup were rare, and patients should be treated by more effective and safer means. Additionally, its potentialside effects, such aslethargy, can be confused with the poison's effects, complicatingdiagnosis. The use of ipecac may also delay the use of other treatments (e.g.,activated charcoal,whole bowel irrigation, or oralantidotes) or make them less effective.
Ipecac has been used by people withbulimia nervosaas a means to achieveweight lossthrough inducedvomiting.  Repeated use in this manner is believed to cause damage to the heart and muscles, which can ultimately result in the user's death.Misuse of ipecac has been blamed for the death of singerKaren Carpenterin 1983 who suffered from anorexia nervosa.It has also been used as an agent forMünchausen syndrome by proxy.
The actions of ipecac are mainly those of majoralkaloids,emetine(methylcephaeline) andcephaeline.They both act locally by irritating the gastricmucosaand centrally by stimulating the medullarychemoreceptor trigger zoneto induce vomiting.
Ipecac has been found to have minimal health benefits, and is ultimately ineffective at purging the body of poisonous substances. It was initially discontinued due to production costs and lack of raw materials. As the ASHP advises:  "Ipecac syrup is no longer recommended for routine management of outpatient ingestions of medications or other chemicals." Humco and Paddock Laboratories, the last two companies to continue manufacturing ipecac syrup, both stopped production in 2010.
A heavily cited position statement outlines critical details of its effectiveness: