Syrup of ipecac was once a common household product used to induce vomiting in cases of accidental poisoning. However, changes in medical recommendations and regulation over the past couple decades have made syrup of ipecac increasingly hard to obtain for home use. This article will examine the history of syrup of ipecac, discuss medical guidance around its use, look at its current legal status, and provide alternatives for safely using emetics when medically advised.
What is Syrup of Ipecac?
Syrup of ipecac is a medication derived from the ipecacuanha plant that has emetic (vomiting-inducing) properties.[1] It works by irritating the stomach lining and activating the vomiting center in the brain.[2] It has been used since the 1960s as a first aid measure to induce vomiting after ingestion of poisons or drugs.[3]
By causing vomiting, syrup of ipecac can help quickly remove toxic substances from the stomach before they are absorbed into the bloodstream. This can help prevent adverse effects or reduce their severity. It was previously recommended as a first aid measure to keep in the home for early treatment of accidental poisoning.[4]
However, as discussed below, recommendations around its use have changed significantly over the past couple of decades.
How Does Syrup of Ipecac Work?
Syrup of ipecac contains two active compounds called emetine and cephaeline derived from the ipecac plant. These compounds irritate the lining of the stomach and gastrointestinal tract, stimulating the vomiting reflex.[5]
Specifically, emetine and cephaeline act on the chemoreceptor trigger zone (CTZ) in the brainstem. The CTZ controls the vomiting reflex and contains receptors that sense irritants and toxins in the blood. By activating these receptors, syrup of ipecac triggers prolonged vomiting typically starting within 20-30 minutes of ingestion.[6]
This vomiting can continue for up to 2 hours as the emetine is slowly absorbed into the bloodstream and subsequently excreted in bile, further irritating the GI tract.[7]
History of Syrup of Ipecac
Ipecacuanha has a long history of medicinal use dating back to the 1500s when European settlers learned of its emetic properties from indigenous South American cultures.[8] Through the 17th-19th centuries, ipecac was used to treat dysentery, fever, and respiratory ailments.[9]
In the 1960s, the specific formulation of syrup of ipecac was developed as an emergency treatment for poisoning. A New York hospital pharmacist named Aaron Klugman prepared a standardized formulation using ipecac fluid extract, glycerin, and syrup.[10] This became adopted in hospitals and eventually marketed as an over-the-counter product for home use.
Through the 1970s and 80s, syrup of ipecac became a common household first aid item recommended by poison control centers and pediatricians for early treatment of poisonings while emergency care was sought.[11] This at-home availability was thought to allow for rapid administration within the critical one-hour window after ingestion.
However, recommendations changed as more research emerged on risks and declining benefit of routine ipecac-induced emesis in poisoning management.
Medical Guidance on Using Syrup of Ipecac
Medical guidance on using syrup of ipecac for poisonings has evolved significantly over the past few decades from routine use to being no longer recommended in most situations.
Changing Recommendations
In the 1980s-90s, national guidelines routinely recommended syrup of ipecac administration for pediatric poisonings based on household availability and possible benefit.[12] However, emerging research led to re-evaluation of its risks versus benefits.
A 1997 NIH consensus statement was the first national recommendation against routine ipecac use in poisoning, citing lack of evidence for decreased morbidity or mortality.[13] In the early 2000s, poison control centers changed protocols to use ipecac only for select oral poisoning cases under medical consultation.[14]
In 2004, a review by the American Academy of Pediatrics and American Association of Poison Control Centers strongly advised against routine home use of ipecac.[15] They cited the lack of proven benefit versus risks of aspiration, delayed care, and ineffective decontamination.
Current poison control and medical toxicology guidance uniformly recommend against using ipecac even in hospital settings.[16] Intravenous antiemetics like ondansetron are used instead for vomiting induction when medically indicated.
Reasons for Changing Guidance
There are several reasons syrup of ipecac lost favor as a poisoning treatment recommendation:
– **Lack of proven benefit** – Although widely used for decades, there is no human research proving ipecac improves poisoning outcomes or reduces morbidity/mortality.[17] Any benefit is theoretical and could be offset by risks.
– **Risk of aspiration** – Inducing prolonged vomiting can increase aspiration risk. One study found ipecac administration multiplied the rate of aspiration 7.5 times versus no emesis.[18] Aspiration of even small amounts of caustic cleaning agents or hydrocarbons can cause severe chemical pneumonitis.
– **Delayed use of activated charcoal or antidotes** – For some poisonings, rapidly administering activated charcoal or specific antidotes is preferred over emesis. Ipecac delays their use and reduces gastrointestinal absorption.
– **Decreased poison elimination** – Research shows ipecac actually decreases elimination of some toxins like phenobarbital, possibly due to slowed gastric emptying.[19]
– **Need for earlier activated charcoal use** – Current consensus emphasizes early activated charcoal use, which binds toxins before they are absorbed. Ipecac makes charcoal administration impractical.
– **Advances in gastrointestinal decontamination** – Gastric lavage is now preferred over ipecac emesis for decontamination in many poisoning situations.
– **Limited indications** – Evidence suggests ipecac may only be beneficial within 1 hour of ingestion for select oral toxin exposures. This makes timely administration unlikely and routine use excessive.
Is Syrup of Ipecac Available Over the Counter?
Given the medical guidance advising against routine use, syrup of ipecac is no longer available as an over-the-counter medication in the United States. It is classified as a prescription-only drug that requires physician authorization.
Over-the-Counter Status
Starting in the 1960s, pre-packaged syrup of ipecac was widely marketed directly to consumers as an OTC product to keep in their medicine cabinet for early treatment of accidental poisonings.
However, concerns over inappropriate use and declining medical recommendations prompted regulatory action to make syrup of ipecac available only under medical supervision. In 2010, the FDA ruled that OTC sales of syrup of ipecac should no longer be allowed. Drug companies were ordered to stop marketing it to consumers as an OTC medication.[20]
Now syrup of ipecac can only be legally obtained in the U.S. with a prescription from a licensed medical provider. Most pharmacies do not keep it routinely in stock but may be able special order it if medically necessary.
Exceptions
There are a few exceptions where OTC sale technically may still be permitted in certain states:
– **Remaindered inventory** – After the 2010 FDA ruling, some remaining shop inventory was allowed to be sold OTC until depleted.
– **Pharmacy exceptions** – A small number of states (such as Kentucky, New Mexico, and West Virginia) still classify ipecac syrup as non-prescription in their pharmacy regulations.[21] However, most pharmacies in these states voluntarily follow the national FDA guidance.
So while minor exceptions exist, it is unlikely that consumers will find syrup of ipecac readily available without a prescription. Online sales from unauthorized dealers also risk obtaining counterfeit or outdated product.
Alternatives to Syrup of Ipecac for Inducing Vomiting
While no longer recommended for home use, there are situations where a physician may advise inducing vomiting after poisoning. However, syrup of ipecac is rarely used, even in hospitals. Alternatives include:
Activated Charcoal
Activated charcoal is the most common agent used to absorb toxins before they enter the bloodstream. Multiple doses are preferred over ipecac for decontamination in many poisonings. It is safer and more effective if given early.[22]
Gastric Lavage
Gastric lavage involves washing out the stomach through a tube inserted through the nose or mouth. It removes larger amounts of toxins than vomiting and is preferred over ipecac in many situations.[23]
Intravenous Antiemetics
Medications given through an IV like ondansetron are used to induce vomiting when needed in hospital settings. They are preferred over ipecac since the timing and duration can be controlled.[24]
Finger Stimulation of the Throat
The back of the throat can sometimes be stimulated with a finger to induce vomiting as a temporary emergency measure. However, this is not preferred over charcoal or lavage.
Conclusion
While syrup of ipecac was once a common antidote in the home, it is now considered obsolete and no longer recommended for routine poisoning treatment. Safer and more effective options exist. Syrup of ipecac is no longer available over the counter and can only be obtained with a prescription. However, it is rarely prescribed even in hospitals.
Frequently Asked Questions
Is syrup of ipecac available over the counter?
No, syrup of ipecac is not available for sale over the counter without a prescription in the United States. In 2010, the FDA ruled that ipecac syrup was no longer considered safe or effective for OTC use in poisonings.
What countries can you buy ipecac syrup over the counter?
Very few countries still allow OTC sale of syrup of ipecac. Canada prohibited OTC sales in 2011. In the UK, New Zealand, and Australia, it is available only by prescription. Some countries in South America and Africa may still permit OTC purchase in pharmacies.
Can you buy ipecac syrup online?
It is technically illegal to buy or sell ipecac syrup online without a prescription in the U.S. Any products marketed online without requiring a prescription are likely outdated or counterfeit. The FDA has warned against purchasing ipecac online.
Is syrup of ipecac available in any stores?
Syrup of ipecac should no longer be available for sale in major retail stores without a prescription. Some independent pharmacies in a few U.S. states may still sell leftover inventory over the counter while transitioning to follow FDA guidelines. But widespread OTC availability has been phased out.
Where can you get syrup of ipecac?
The only way to legally obtain syrup of ipecac is with a prescription from a licensed physician or other medical provider. A prescription is required for purchase in all pharmacies. In most cases, it would need to be special ordered since demand is low. Very limited OTC sale may still occur in some independent pharmacies.
Can you still buy syrup of ipecac over the counter?
No, OTC sales of syrup of ipecac are no longer permitted in the U.S. after the FDA prohibited its use as a poison treatment in 2010. Any products still being sold over the counter are outdated inventory or mislabeled products, since syrup of ipecac now legally requires a prescription.
What can you use instead of syrup of ipecac?
Medical alternatives include activated charcoal tablets to prevent toxin absorption, gastric lavage to flush toxins from the stomach, or IV antiemetics to induce vomiting when medically necessary. Finger stimulation of the throat may prompt vomiting as a temporary emergency measure.
When should you not use syrup of ipecac?
Do not use syrup of ipecac for poisoning treatment without specific medical direction, as its use is no longer recommended. It should not be used routinely in any ingestions. Contraindications include ingestion of corrosives, hydrocarbons, or in patients at risk of seizure or unable to protect their airway.
Can you buy ipecac for dogs?
Syrup of ipecac has also lost favor as a veterinary emetic due to similar safety concerns. However, some formulations may still be available by veterinary prescription only. Over-the-counter sales for dog owners are unlikely. Activated charcoal may be advised instead by a veterinarian.
How do you use syrup of ipecac?
If prescribed, follow medical instructions carefully. Do not take syrup of ipecac without guidance, as vomiting should be induced only in certain ingestions. The typical dose is 15 mL for children or 30 mL for adults, followed by a glass of water. It must be used within 1 hour of ingestion to be effective.
The Bottom Line
Syrup of ipecac was once a common household product for treating poisonings, but changes in medical practice have made it obsolete. Safer and more effective options exist that do not have the risks associated with induced vomiting.
Syrup of ipecac no longer has proven benefits versus risks that justify routine use. It now requires a prescription and is rarely prescribed, even in hospitals. While limited over-the-counter availability remains in a few locations, syrup of ipecac is functionally no longer an option for at-home use.
