Syrup of ipecac … a nauseating story

Clinical
By
Dr Leigh Dayton
-
Syrup of ipecac

From hero to zero for the anti-poisoning poison.

It is debatable as to who gets the credit for bringing the key ingredient of syrup of ipecac from Brazil to Paris centuries ago. Did Piso, a Dutch physician, first bring a quantity of the dried root ipecacuanha – known as ipecac – in 1649? Or was it a traveller named Legros in 1872?1,2

Regardless, sources agree that in 1680 a physician named Helvetius – himself of dubious credentials – used the root in a medicine for dysentery. Legend has it that Helvetius’s secret preparation cured the son of Louis XIV. Impressed, the French government bought the formula and made it public in 1688.2,3

Use of ipecac soared in the 19th century thanks to English physician and privateer Thomas Dover. He combined ipecac with powdered opium and lactose in a product he named Dover’s Powder. Used to treat dysentery and fever, it was available in Britain until the 1960s and in India until as recently as 1994.4

By the 20th century, chemists were using alcohol to extract the alkaloids cephaeline and emetine (methylcephaeline) from ipecac root. Combined with glycerine, sugar and methylparaben, the result was a product designed to induce vomiting after exposure to poisons: syrup of ipecac (SOI).5,9

Mechanism of action

Ipecac irritates the stomach lining and chemically stimulates the chemoreceptor trigger zone in the medulla oblongata of the central nervous system, thereby inducing near-immediate vomiting.5 Hence the original Brazilian name Ipecacuanha, or ‘small plant causing vomiting’.3 Persistent vomiting, lethargy and diarrhoea are common adverse effects.

More severe complications include aspiration pneumonia, Mallory-Weiss tears, pneumomediastinum, and gastric rupture.5, 6, 9

Rise of syrup of Ipecac

Given its emetic effect, poison centres administered SOI to patients prior to referral to the emergency department.8 They urged households, especially those with young children, to keep SOI.9 Prestigious organisations including the American Academy of Pediatrics, the American Association of Poison Control Centres, the American Medical Association and the US Food and Drug Administration’s (FDA) advisory board called for the FDA to approve over-the-counter sales. It did so in 1965. Australia followed suit.5,9 A 1966 United States magazine article reflected SOI’s popularity.

‘When poisoning does occur, a little ipecac … is incomparably superior to sticking a finger down a child’s throat.’

Decline and fall

Gradually evidence mounted of the scant proof that SOI was safe and effective.5 In fact, SOI could reduce the use of effective treatments like activated charcoal.12

In 1997, the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists released a position paper questioning its use.10 Subsequent reviews in 2004 and 2013 confirmed the findings.11 Australia followed suit.14 Ipecac was effectively dead.15

In 2008 the three remaining manufacturers stopped SOI production.13

BUT … a no-frills but successful recording label, thrives. Its motto: ‘Ipecac Recordings is here to purge you of the drek that’s been rotting in your tummies.’15

References

  1. Com. Ipecacuanha.
  2. Druett J. Rough Medicine: Surgeons at sea in the age of sail. [Internet] New York: Routledge; 2001. p. 61–62.
  3. E.C. A brief history of ipecac (ipecachuanha). Pediatrics 1970;46(1):96.
  4. Banatvala J. Thomas Dover: doctor, privateer, and rescuer of Robinson Crusoe. BMJ 2016;355:i6516.
  5. Benzoni T, Gibson J. Ipecac. [Internet] StatPearls Publishing LLC. 2019. At: www.ncbi.nlm.nih.gov/books/NBK448075/
  6. Committee on Injury, Violence, and Poison Prevention. American Academy of Pediatrics. Poison Treatment in the Home. 2003;112(5):1182–1185.
  7. Galton L. New lifesaver for your medicine chest. [Internet] Parade. 1966 Jun 4.
  8. Manoguerra AS, Cobaugh DJ. Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons. Clinical Toxicology. 2005;43(1):1–10.
  9. King U. Less is more when it comes to emetics. Medical Republic. 2016 Apr 26.
  10. Krenzelok EP, McGuigan M, Lheur P. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997;35(7):699–709.
  11. American Academy of Clinical Toxicology & European Association of Poisons Centres and Clinical Toxicologists. Position paper: Ipecac syrup. Toxicol Clin Toxicol 2004;42(2):133–43.
  12. IPECAC.
  13. Summit Medical Group. Correspondence. Syrup of IPECAC: References. Discontinued 2008.
  14. Therapeutic Goods Administration. Approval, under subsection 7d(1) of the Therapeutic Goods Act 1989, of form for providing product information for a restricted medicine or other medicine in relation to which the secretary requires product information to be provided. Note 5, p. 5.
  15. IPECAC Recordings. About Ipecac recordings.