Toxicology of ipecac: a review

Identification of Combinations of Approved Drugs With Synergistic Activity Against Ebola Virus in Cell Cultures

Background

A need to develop therapeutics to treat Ebola virus disease patients in remote and resource-challenged settings remains in the wake of the 2013-2016 epidemic in West Africa. Toward this goal, we screened drugs under consideration as treatment options and other drugs of interest, most being small molecules approved by the Food and Drug Administration. Drugs demonstrating in vitro antiviral activity were advanced for evaluation in combinations because of advantages often provided by drug cocktails.

Methods

Drugs were screened for blockade of Ebola virus infection in cultured cells. Twelve drugs were tested in all (78 pair-wise) combinations, and 3 were tested in a subset of combinations.

Results

Multiple synergistic drug pairs emerged, with the majority comprising 2 entry inhibitors. For the pairs of entry inhibitors studied, synergy was demonstrated at the level of virus entry into host cells. Highly synergistic pairs included aripiprazole/piperacetazine, sertraline/toremifene, sertraline/bepridil, and amodiaquine/clomiphene.

Conclusions

Our study shows the feasibility of identifying pairs of approved drugs that synergistically block Ebola virus infection in cell cultures. We discuss our findings in terms of the theoretic ability of these or alternate combinations to reach therapeutic levels. Future research will assess selected combinations in small-animal models of Ebola virus disease.

Effectiveness of emetics to study plastic ingestion by Leach's Storm-petrels (Oceanodroma leucorhoa)

Most plastic ingestion studies rely on dissection of dead birds, which are found opportunistically, and may be biased. We used Leach's Storm-petrels (Oceanodroma leucorhoa) in Newfoundland to study the effect of dose volume, and the efficacy of emesis using syrup of ipecac as an emetic. Ipecac is a safe method of non-lethally sampling stomach contents, and recovered all ingested plastic. Almost half the storm-petrels sampled had ingested plastic, ranging from 0 to 17 pieces, and weighing 0.2-16.9 mg. Using the Ecological Quality Objective for Northern Fulmars, adjusted for storm-petrels smaller size, 43% exceeded the threshold of 0.0077 g of plastic. Many adult seabirds offload plastic to their offspring, so storm-petrel chicks likely experience a higher plastic burden than their parents. The ability to study plastic ingestion non-lethally allows researchers to move from opportunistic and haphazard sampling to hypothesis-driven studies on a wider range of taxa and age classes.

Predicting the emetic liability of novel chemical entities: a comparative study

BACKGROUND AND PURPOSE

Emesis is a multi-system reflex, which is usually investigated using in vivo models. The aim of the study is to compare the response induced by emetic compounds across species and investigate whether dogs, ferrets and rats are all similarly predictive of humans.

EXPERIMENTAL APPROACH

A systematic review was carried out and relevant publications were identified from PubMed. The search was restricted to four species (human, dog, ferret, rat) and ten compounds representative of various mechanisms of emesis induction (apomorphine, cisplatin, cholecystokinin octapeptide, copper sulphate, cyclophosphamide, ipecacuanha, lithium chloride, morphine, nicotine, rolipram).

KEY RESULTS

1046 publications were reviewed, and 311 were included, the main reason for exclusion was the lack of quantitative data. Emetic or pica data were extracted as incidence, intensity or latency. All three animal species identified emetic liability but interspecies differences for dose sensitivity were detected.

CONCLUSIONS AND IMPLICATION

These results suggest that emetic liability can be reliably identified in a common laboratory species such as the rat. However, to evaluate the characteristics of the emetic response, no animal species is a universal predictor of emetic liability and the choice of species should be an informed decision based on the type of compound investigated. Limitations relating to the conduct and reporting of emesis studies were identified, the main ones being the lack of comparable outcome measures between human and animal data, and the limited availability of human data in the public domain.

Drugs and pharmaceuticals: management of intoxication and antidotes

The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life support--airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, L-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.

Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion

Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.

Pediatric Toxicology

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.

Is syrup of ipecac still for sale? Comparison of pharmacies in a large urban area--2003 versus 2005

There has been considerable publicity about the lack of benefit and potential dangers of syrup of ipecac. In November 2003, the American Academy of Pediatrics recommended against its use. Pharmacies in Houston, Texas were surveyed by telephone before (survey 1) and after (survey 2) the American Academy of Pediatrics' recommendation to determine whether ipecac availability changed. There were 126 pharmacies interviewed at survey 1, and 128 interviewed at survey 2. Pharmacies in survey 1 were more likely than those in survey 2 to sell ipecac (79% versus 64%, P < .01) and to have it in stock (75% versus 48%, P < .001). Pharmacies mostly stored ipecac on the shelves (67%, survey 1; 59%, survey 2, P = .27). Although syrup of ipecac availability has declined significantly, it is still available in more than 50% of pharmacies. Health care providers should advise against its use and advocate that pharmacies remove it.

The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives

OBJECTIVE

To describe the frequency of alternative medication use in bulimia nervosa (BN), and to review available nonprescription emetic (ipecac) and laxative products and their potential toxicities.

METHOD

Survey data were collected from 39 consecutive treatment-seeking patients with BN or subthreshold BN. Survey data of the available nonprescription and herbal products from local retail stores were also collected. Toxicology information was reviewed on these agents from MEDLINE and herbal textbooks.

RESULTS

Ipecac use occurred in 18% of the 39 patients. Laxatives had been used at some point to control weight or "get rid of food" by 67% of the patients. Of these, 31% had abused laxatives during the month prior to evaluation. In the product survey, 248 laxative-containing products were identified.

CONCLUSION

There are numerous laxative products readily available to patients, and many of them have significant associated toxicities. Patients with BN tend to endorse high rates of laxative use. While ipecac is used infrequently, it can have deleterious consequences. Patients with BN should be screened for use of both ipecac and laxatives and should be educated about the potential consequences associated with the misuse of these agents.

Cardiovascular complications of eating disorders

Eating disorders (anorexia nervosa and bulimia) are associated with the highest mortality rate of any psychiatric disorder. Much of this mortality and morbidity stem from cardiovascular complications such as arrhythmia related to a prolonged QTc interval and/or electrolyte disorders, hypotension, and bradycardia. Structurally, the heart in patients with eating disorders is atrophic, which may relate to longstanding hypovolemia. These patients have low cardiac output and demonstrate increased peripheral vascular resistance despite the presence of hypotension. The treatment of eating disorders is incremental caloric feeding, which can have its own intrinsic cardiovascular risk (refeeding syndrome) manifested by arrhythmia, tachycardia, congestive heart failure, and sudden cardiac death. Patients will require close monitoring and slower refeedings to minimize the risk of these complications.

Munchausen syndrome by proxy caused by ipecac poisoning

OBJECTIVE

To present a case of Munchausen syndrome by proxy caused by ipecac poisoning to increase the awareness of their warning signs and symptoms so that they may be recognized and diagnosed earlier.

CASE

Report of one case of a child who was determined to be a victim of Munchausen syndrome by proxy by ipecac poisoning who was hospitalized multiple times over a 4-year period at 2 different hospitals before an accurate diagnosis was made.

Astonishing diversity of natural surfactants: 6. Biologically active marine and terrestrial alkaloid glycosides

This review article presents 209 alkaloid glycosides isolated and identified from plants, microorganisms, and marine invertebrates that demonstrate different biological activities. They are of great interest, especially for the medicinal and/or pharmaceutical industries. These biologically active glycosides have good potential for future chemical preparation of compounds useful as antioxidants, anticancer, antimicrobial, and antibacterial agents. These glycosidic compounds have been subdivided into several groups, including: acridone; aporphine; benzoxazinoid; ergot; indole; enediyne alkaloidal antibiotics; glycosidic lupine alkaloids; piperidine, pyridine, pyrrolidine, and pyrrolizidine alkaloid glycosides; glycosidic quinoline and isoquinoline alkaloids; steroidal glycoalkaloids; and miscellaneous alkaloid glycosides.

Criminal Poisoning: Munchausen by Proxy

The diagnosis and subsequent prosecution of Munchausen by proxy (MBP) cases require the collaborative teamwork of health care teams, laboratory personnel, law enforcement, and social services. Poisoning occurs in a significant number of the MBP cases with a diverse variety of agents used. To aid laboratory professionals in determining the appropriate toxicology tests to perform in such criminal cases, health care professionals must focus their testing requests on substances that correspond to the victim's signs, symptoms, and ancillary test values. This article reviews MBP, with particular focus on poisoning agents that have been used in past reported cases.

Medically Unexplained Myopathy Due to Ipecac Abuse

The use of ipecac, once recommended as an emetic for use in toxic ingestions, has more recently been discouraged for use in home and emergency room settings. It remains readily available, and has been associated with abuse in eating disorders and Munchausen syndrome by proxy. This case discusses an adolescent boy who surreptitiously abused ipecac in the context of distress over parental conflict, and the extensive medical workup undertaken to evaluate unexplained symptoms of proximal muscle weakness, abdominal pain, and, eventually, cardiomyopathy that are sequelae of ipecac toxicity. Clinicians should be alerted to ipecac ingestion with similar presentation.

Disorders of Fuel Metabolism: Medical Complications Associated with Starvation, Eating Disorders, Dietary Fads, and Supplements

Disorders of fuel metabolism as they relate to abnormal fuel intake,abnormal fuel expenditure, and dietary supplements are the focus of this article. The emergency physician should be aware of the medical complications that can occur as a result of starvation states,eating disorders, fad diets, hypermetabolic states, and ergogenic aids. Knowledge and understanding of the complications associated with these disorders will facilitate the diagnosis and management of patients who present to the emergency department with any of the disorders reviewed.

Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons

The use of gastric emptying techniques, including ipecac-induced emesis, in the management of poisoned patients has declined significantly in recent years. Historically, poison centers used ipecac syrup in two ways. Ipecac syrup was administered to patients prior to referral to the emergency department in attempts to start the gastric emptying process as early as possible. Additionally, poison centers used ipecac syrup in attempts to keep patients from requiring referral to medical facilities. In these situations, ipecac syrup was administered in the home and poison center staff performed follow-up telephone calls to gauge progress and outcome. Studies to determine the effectiveness of ipecac syrup demonstrate that it induces vomiting in a high percentage of people to whom it is administered and that it decreases the gastrointestinal absorption of ingested substances in a time-dependent fashion. However, the effectiveness of ipecac syrup in affecting patient outcome has not been studied in adequate clinical trials. Its effectiveness in preventing drug absorption has only been documented for a limited number of substances and is substantially reduced if it is given more than 30-90 minutes following ingestion of the toxic material. There are potentially significant contraindications, adverse effects and related problems associated with the use of ipecac syrup. It is the consensus of the panel that the circumstances in which ipecac-induced emesis is the appropriate or desired method of gastric decontamination are rare. The panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations in which: there is no contraindication to the use of ipecac syrup; and there is substantial risk of serious toxicity to the victim; and there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal); and there will be a delay of greater than 1 hour before the patient will arrive at an emergency medical facility and ipecac syrup can be administered within 30-90 minutes of the ingestion; and ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. In such circumstances, the administration of ipecac syrup should occur only in response to a specific recommendation from a poison center, emergency department physician, or other qualified medical personnel. The panel decided not to address the issue of whether ipecac should remain a nonprescription, over-the-counter product. The panel does not support the routine stocking of ipecac in all households with young children but was unable to reach consensus on which households with young children might benefit from stocking ipecac. Instead, the panel concluded that individual practitioners and poison control centers are best able to determine the particular patient population, geographic and other variables that might influence the decision to recommend having ipecac on hand.

Betamethasone does not prevent nausea and vomiting induced by ipecacuanha

BACKGROUND

Corticosteroids reduce the incidence of PONV but the mode of action is not known. The purpose of this study was to evaluate if betamethasone has serotonin (5-HT) antagonistic effects. Ipecacuanha is known to release serotonin and therefore it was used to induce nausea and vomiting. The 5-HT3 antagonist ondansetron was used as a control substance.

METHODS

In a randomized, double-blind, cross-over, placebo-controlled study 10 healthy male and female volunteers (6 M/4F), mean age 19.5 (18-23) years, mean weight 69.7 (53-84) kg, were studied on three occasions separated by at least 1 week. They were randomly allocated to receive pretreatment with betamethasone 8 mg, ondansetron 8 mg, or normal saline 2 ml as placebo on each occasion, 15 min before oral ingestion of 30 ml of Ipecacuanha syrup. After ingestion of ipecacuanha, vomitings were recorded and the intensity of nausea was estimated with a visual analog scale during 2 h.

RESULTS

During the first 2 h after ingestion of ipecacuanha nine of the 10 volunteers vomited both after betamethasone and placebo. No volunteer vomited after ondansetron (P < 0.01 vs. betamethasone and placebo). The max VAS for nausea was significantly higher after betamethasone and placebo compared to ondansetron (P < 0.01). There were no statistically significant differences of the max VAS for nausea between betamethasone and placebo.

CONCLUSION

This study in volunteers has shown that betamethasone does not prevent nausea and vomiting induced by oral intake of ipecacuanha syrup. As ipecacuanha releases 5-hydroxytryptamin, it can be concluded that betamethasone does not have 5-HT3 antagonistic effects.

Toxicological aspects of Kampo medicines in clinical use

Among 210 medicinal prescriptions used in present-day Japan, the clinical uses and the acute, chronic and mutagenic toxicity study of 16 Kampo (Japanese herbal) medicines are summarized. These Kampo medicines are classified into two categories; eight prescriptions containing Bupleurum root (Bupleurum falcatum L.) such as Sho-saiko-to and Saiko-keishi-to, and eight prescriptions not containing Bupleurum root such as Juzen-taiho-to and Ninjin-yoei-to. Studies of some potential interaction between herbal medicine and western drugs are also described.

Studies for the emetic mechanisms of ipecac syrup (TJN-119) and its active components in ferrets: involvement of 5-hydroxytryptamine receptors

Ipecac syrup, prepared from a galentical ipecac, contains the nauseant alkaloids cephaeline and emetine. The involvement of receptors and serotonin- and dopamine-metabolizing enzymes in the emesis induced by ipecac syrup and these components was investigated. 1) In ferrets, the selective 5-HT3-receptor antagonist ondansetron (0.5 mg/kg, p.o.) prevented each emesis induced by TJN-119 (0.5 mL/kg, p.o.), cephaeline (0.5 mg/kg, p.o.) and emetine (5.0 mg/kg, p.o.), but the intraperitoneal administration of the selective dopamine D2-receptor antagonist sulpiride failed to significantly suppress the TJN-119, cephaeline and emetine-induced emesis at a dose of 0.1 mg/kg that blocked apomorphine-induced emesis. 2) In the receptor binding assays, cephaeline and emetine had a distinct affinity to 5-HT4 receptor, but no or weak affinity to 5-HT1A, 5-HT3, nicotine, M3, beta1, NK1, and D2 receptors. 3) Cephaeline and emetine did not affect activities of metabolic enzymes of 5-HT and dopamine (MAO-A, MAO-B, tryptophan 5-hydroxylase and tyrosine hydroxylase) in vitro. These results suggest that 5-HT3 receptor plays an important role in the emetic action of TJN-119, cephaeline and emetine, and the 5-HT4 receptor may be involved in their mechanisms.

Absorption, distribution and excretion of 3H-labeled cephaeline- and emetine-spiked ipecac syrup in rats

The maximum plasma radioactivity levels of tritium (3H)-labeled cephaeline, (24.3, 28.7 and 40.6 ng eq./mL) were reached at 2.00-3.33 hours following oral dosing of ipecac syrup. The maximum plasma radioactivity levels of 3H-emetine (2.71, 6.47 and 9.62 ng eq./mL) were reached at 1.08-2.33 hours following ipecac syrup administration. The Cmax values of 3H-cephaeline were followed by a biexponential decrease with half-lives t 1/2(lambda z) of 3.45-9.40 hours. On the other hand, the t 1/2 (lambda z)of 3H-emetine were 65.4-163 hours, which revealed a biexponential decrease. The radioactivity of both tritium-labeled compounds was distrbuted maximally in most tissues at 24 hours. For 3H-cephaeline, the maximum radioactivity levels in tissues were approximately 100-150 times greater than in plasma. For 3H-emetine, the radioactivity levels in tissues were approximately 1000-3000 times greater than in plasma. Tissue radioactivity levels decreased at a substantially slower rate than that observed in plasma. Tissue radioactivity of 3H-emetine decreased more slowly than that of 3H-cephaeline. For 3H-cephaeline, the cumulative biliary excretion of radioactivity was 57.5% at 48 hours. The cumulative urinary and fecal excretion of radioactivity in these rats was 16.5% and 29.1%, respectively, of the dose at 48 hours following dosing. For 3H-emetine, the cumulative biliary excretion of radioactivity was 12.5% at 48 hours. The cumulative urinary and fecal excretion of radioactivity was 9.4% and 34.1%, respectively, of the administered dose at 48 hours. The radioactivity level of 3H-emetine remaining in the carcasses at 48 hours was equivalent to approximately 50% of the dose. A portion of each tritium-labeled compound was subjected to entero-hepatic circulation. Thus, the absorption rate of 3H-cephaeline and 3H-emetine was estimated to be approximately 70% on the basis of the data obtained from excretion studies. There was no difference in the absorption process between these two compounds. However, the difference was admitted in the biliary clearance, which is the main excretion route of both compounds. Delayed excretion of 3H-emetine may be primarily due to its resorption as related to entero-hepatic circulation and tissue retention. This study has determined the absorption, distribution and excretion of 3H-cephaeline and 3H-emetine in rats.

Biotransformation of the ipecac alkaloids cephaeline and emetine from ipecac syrup in rats

The metabolism of cephaeline and emetine, which are the primary active components of ipecac syrup, were investigated in rats. Cephaeline-6'-O-glucuronide was found to be a biliary metabolite of cephaeline. Cephaeline (6'-O-demethylemetine) and 9-O-demethylemetine were observed to be enzyme-hydrolyzed biliary metabolites of emetine. Cephaeline was conjugated to glucuronide, while emetine was demethylated to cephaeline and 9-0-demethylemetine, and may be conjugated to glucuronides afterwards. Urine, feces and bile were collected from rats within 48 hours following the administration of ipecac syrup containing tritium (3H)--labeled cephaeline or emetine. Metabolites were separated and quantified by thin layer chromatography (TLC) or high-performance liquid chromatography (HPLC). Biliary and urinary excretion rates of 3H-cephaeline were 57.5% and 16.5% of the dose, respectively. Cephaeline-6'-O-glucuronide was comprised 79.5% of biliary radioactivity and 84.3% of urinary radioactivity. Unchanged cephaeline was detected in 42.4% of the dose in feces. Biliary excretion rate of 3H-emetine was 6.9% of the dose. Emetine, cephaeline and 9-0-demethylemetine comprised 5.8%, 43.2% and 13.6% in hydrolyzed bile, respectively. There were no emetine-derived metabolites in urine or feces. The occurrence of unchanged emetine was 6.8% and 19.7% of the dose in urine and feces, respectively.

High-performance liquid chromatographic assay with fluorescence detection for the determination of cephaeline and emetine in human plasma and urine

A high-performance liquid chromatographic assay method for the quantitation of ipecac alkaloids (cephaeline and emetine) in human plasma and urine is described. Human plasma or urine was extracted with diethylether under alkaline conditions following the addition of an internal standard. Concentrations of alkaloids and internal standard were determined by octadecylsilica chromatographic separation (Symmetry C18 columns, plasma analysis; 15 cmx4.6 mm I.D., 5 microm particle size, urine analysis; 7.5 cmx4.6 mm I.D., 5 microm particle size). The mobile phase consisted of buffer (20 mmol/l 1-heptanesulfonic acid sodium salt, adjusted to pH 4.0 with acetic acid)-methanol (51:49, v/v). Eluate fluorescence was monitored at 285/316 nm. The lowest quantitation limits of cephaeline and emetine were 1 and 2.5 ng/ml, respectively, in plasma, and 5 ng/ml in urine. Intra- and inter-day relative standard deviations were below 15%. The assay is sensitive, specific and applicable to pharmacokinetic studies in humans.

Single dose pharmacokinetics of syrup of ipecac

Syrup of ipecac (SI) has been used medicinally since the 1500s; however, little is known about the pharmacokinetics in humans of SI's active ingredients, emetine and cephaeline. The objective of this study was to evaluate the rate of absorption and the rate of elimination of emetine and cephaeline. Ten healthy, adult, human volunteers between 18 and 45 years of age who were of ideal body weight (body mass index 20-25) completed this study. After an overnight fast, 30 mL SI were ingested. Blood samples were collected 30, 45, 60, 90, 120, 150, and 180 minutes post-ingestion and urine was collected throughout the study period. Plasma and urine concentrations of emetine and cephaeline were measured by reverse-phase HPLC with fluorescence detection. In virtually all subjects, emetine and cephaeline were detected within 5-10 minutes of dosing with the time to maximum concentration being approximately 20 minutes. The mean areas under the concentration-time curve (AUC) for both emetine and cephaeline were similar; however, the ratio of mean cephaeline maximum concentration (Cmax) to emetine Cmax was approximately 1.5. Four of the ten subjects exhibited a type of concentration-time profile in which the levels of cephaeline were substantially higher than those of emetine and the levels of cephaeline were substantially higher than noted for the other six subjects. In these remaining six subjects, the levels of emetine and cephaeline were lower than 10 ng/mL at all time-points. An initial elimination phase was noted in some subjects but not in others. Individuals in whom an initial elimination phase was not observed also exhibited low levels of both alkaloids as compared with the other subjects suggestive of a slower distribution phase. Less than 0. 15% of the administered emetine and cephaeline was recovered in the urine at 3 hours. No relationship between vomiting episodes and peak concentrations of emetine or cephaeline was found. Administration of SI results in rapid appearance and disappearance of emetine and cephaeline in plasma becoming almost undetectable at 3 hours. Very little of either alkaloid is eliminated in the urine within this time period, suggesting extensive distribution. The length of time that an administered dose of SI can result in the detection of emetine and/or cephaeline in the urine has not been determined; future studies in humans are required.

Ipecac toxicity in "Munchausen syndrome by proxy"

The authors report a case that offers insight into the diagnostic challenges of "Munchausen Syndrome by Proxy." Initial presentation with history of fever and later with intractable vomiting led to invasive and expensive diagnostic evaluation before confirming the diagnosis. Certain toxic effects of emetine were clinically noted. Biochemical and clinical improvement were clearly demonstrated after withdrawal of the toxic agent.

The evaluation of eating and weight symptoms. A comparison of medically ill and eating disorder patients

The purpose of this study was to determine the utility of hospitalization in a medical-psychiatry unit for eating disorder patients. A retrospective chart review of 48 patients given an International Classification of Disease-9 diagnosis of an eating disorder was conducted. Presenting symptoms, functional status using the Karnofsky Index, medical and psychiatric evaluation, diagnosis, treatment, and outcome were evaluated. Patients fell into 1 of 3 groups: those with an active eating disorder and comorbid medical complications (Eating Disorder [ED] positive [POS], n = 25), those with a history of an eating disorder admitted for some other reason (ED history [HX], n = 8), and those with eating or weight symptoms ultimately found to be related to a noneating disorder or primary medical process (ED negative [NEG], n = 15). The ED POS patients were younger (28.1 vs. 49.1 years, P = 0.0001) but had a lower functional status on admission compared with the ED NEG patients (Karnofsky score 51 vs. 72, P = 0.0002). They were more likely to binge eat, restrain intake, and abuse laxatives (P = 0.0001, P = 0.024, P = 0.037, respectively) but did not differ with respect to history of vomiting (P = 0.113). The ED POS patients were more likely to be transferred to a general psychiatry or eating disorder unit. Overall length of stay was greater in this group (44.6 vs. 20.4 days, P = 0.031). Initial evaluation of patients presenting with eating or weight symptoms may be difficult given similarities between the patients with primary eating disorders and those with other underlying medical causes. The medical-psychiatry unit provides comprehensive initial evaluation and treatment of patients with eating and weight symptoms.

Clinical approach to toxicities

Toxicities are a common presenting complaint in the emergency department. This article discusses the clinical approach to the poisoned patient from the initial telephone call by the owner to presentation, management, and monitoring of the patient in the emergency department. Topics discussed include telephone triage, diagnosis, management, and monitoring of the poisoned patient.

Emetine myopathy in a patient with an eating disorder

OBJECTIVE

To alert physicians to the dangers of a readily available, non-prescription drug by describing the clinical and pathological features of myopathy due to chronic poisoning with ipecac syrup in a patient with an eating disorder.

CLINICAL FEATURES

A 27-year-old woman presented in 1991 with a right foot drop, followed a few months later by progressive severe neck and limb weakness associated with dysphagia, faecal incontinence and diffuse body ache. It emerged that she had been consuming increasing quantities of ipecac syrup (up to 200 mL per week) for three months to induce vomiting and weight loss. The serum creatine kinase activity was slightly elevated and electromyographic examination results were in keeping with a necrotising proximal myopathic process. Muscle biopsy showed vacuolar degeneration with myofibrilolysis and fine cytoplasmic body formation, consistent with a diagnosis of emetine myopathy.

INTERVENTION AND OUTCOME

The patient was advised to stop taking ipecac and observed for the next few months. The symptoms resolved gradually and strength returned to normal in four months.

CONCLUSION

Chronic emetine toxicity, with its potentially catastrophic consequences, should be remembered in the evaluation of neuromuscular symptoms in young women, in whom eating disorders are common and often unrecognised.

Ipecac myopathy and cardiomyopathy

Two cases of ipecac myopathy, one with associated cardiomyopathy are reported. Both patients were young women with eating disorders who came to medical attention because of diffuse muscle weakness. Clinical and electromyographic data suggested ipecac myopathy and muscle biopsies confirmed this diagnosis. One patient had associated clinical and echocardiographic evidence of significant cardiomyopathy. The myopathy resolved and the echocardiogram returned to normal after discontinuing the use of ipecac.

Drug overdose — reducing the load

OBJECTIVE

To review available information about various methods for reducing gastrointestinal absorption of a poison or drug.

DATA SOURCES

Articles on overdose and accidental poisoning generated by the Australian Medlars Service and concentrating on the period between 1985 and 1990 were surveyed. Earlier studies were included if relevant.

STUDY SELECTION AND DATA EXTRACTION

English language articles with an emphasis on studies using objective methods to measure individual and comparative efficacy of gastrointestinal decontamination techniques were selected. A total of 65 articles were reviewed.

DATA SYNTHESIS

Gastric emptying procedures (gastric lavage or emesis caused by syrup of ipecac) are only effective if performed within one hour of drug ingestion. Gastric lavage is superior to syrup of ipecac. Oral administration of activated charcoal is more effective than either gastric emptying procedure, and is recommended for most cases of poisoning. Cathartics (sorbitol) can be used with activated charcoal. Whole bowel lavage with polyethylene glycol is indicated in selected cases of potentially lethal overdose where the toxic substance cannot be absorbed by charcoal and has passed the pylorus.

CONCLUSIONS

Children--syrup of ipecac can be given at home to children older than 12 months. Most children who reach hospital can be treated by charcoal alone. ADULTS--Most patients are managed with supportive care and, in the absence of contraindications, a single dose of activated charcoal if seen within four hours of ingestion of the poison or drug. Gastric lavage is used if the patient presents within one hour of ingestion and has clinical features of toxicity.

Abuse of drugs associated with eating disorders

Concomitant bulimia nervosa and drug abuse are common in women. Drugs used by this group include diuretics, emetics, laxatives, and diet pills, as well as alcohol, cigarettes, and illicit street drugs. This paper applies principles from behavioral pharmacology to the problem of drug use by women with bulimia nervosa. The prevalence of use, primary effects, toxicity, detection, tolerance, withdrawal, and effects on appetite and weight are discussed for drugs used by bulimic women to reduce appetite or weight or to induce purging (e.g., diuretics, emetics, laxatives, and diet aids). Alternatives in the diagnosis and treatment of drug use in women with eating disorders are discussed.

Chemical aversion treatment of alcohol dependence

Developments in the application of chemical aversion therapy to the treatment of alcohol dependence are discussed. Historical factors leading to the early use of chemical aversion therapies are delineated and the theoretical underpinnings of chemical aversion interventions are evaluated. Ethical and procedural considerations are addressed and an assessment of the efficacy of the therapy is attempted. Future research activities that would lead to refinement of chemical aversion therapy protocols are highlighted. The effectiveness of chemical aversion treatment of alcohol dependence is discussed vis-a-vis production of condition alcohol-aversion and treatment outcome.

Fluphenazine, ICS 205-930 and dl-fenfluramine differentially antagonise drug-induced emesis in the ferret

The intravenous injection of cisplatin (10 mg/kg), the subcutaneous injection of apomorphine (0.125-1 mg/kg) and lisuride (0.001-0.1 mg/kg), the oral administration of ipecacuanha (0.3-2.4 mg/kg) and the intragastric administration of copper sulphate (25-100 mg/kg), induced a vomiting and retching response in the ferret. Pretreatment with dl-fenfluramine (5 mg/kg i.p.) prevented or reduced the emesis induced by cisplatin, apomorphine, ipecacuanha and lisuride but failed to significantly antagonise copper sulphate-induced emesis. The 5-HT3 receptor antagonist ICS 205-930 (0.1 mg/kg i.p.) prevented emesis induced by cisplatin and ipecacuanha but failed to prevent or significantly reduce the emesis induced by apomorphine, lisuride or copper sulphate. Dopamine receptor antagonists, including fluphenazine (0.1-1.0 mg/kg i.p.) prevented apomorphine- and lisuride-induced emesis but were less potent or had inconsistent actions to antagonise cisplatin- or ipecacuanha-induced emesis and failed to inhibit the emesis induced by copper sulphate. The data indicate that dopamine and/or 5-HT3 receptor systems are involved in drug-induced emesis but that emesis caused by gastric irritation induced by copper sulphate is mediated by different receptor mechanisms.

Management of toxicoses

This article provides information on the detoxification of and supportive care for poisoned animals. Involved are measures to control life-threatening manifestations of toxicoses, to remove agents from the digestive tract, skin, or eyes, and to promote removal of systemically absorbed toxicants. The use of these methods is often of paramount importance in an effort to limit organ damage and to enable a poisoned animal to survive.

Ipecac abuse: a serious complication in bulimia

Ipecac abuse among bulimics is being increasingly reported. The case presented is a 19-year-old female with significant eating-related problems, including frequent binges and daily use of ipecac to induce vomiting. Medical evaluation revealed significant muscle weakness, cardiac impairment, and altered levels of serum enzymes. The physical debilitation caused by the ipecac use dissipated following apparent discontinuation of ipecac ingestion. The symptom presentation and management problems in this case are discussed to alert clinicians involved in consultation about ipecac abuse.

Gastrointestinal decontamination for acute poisoning

Gastric decontamination remains an important element in the therapy of pediatric poisoning; however, several issues remain unresolved. Additional studies, particularly in the clinical setting, are necessary to establish optimal therapeutic recommendations. Based on the data presented in this review, the following general recommendations can be made for gastric decontamination in children: If it is necessary to remove an ingested toxin, ipecac syrup is the preferred method if contraindications to its use are not present. The dose should be 30 ml in children older than 1 year of age and 10 ml in children 6 to 12 months of age. Pending further studies, the use of emetics in children younger than 6 months of age cannot be generally recommended, particularly in the home setting. Gastric lavage should be considered to be of very limited use in pediatric patients. Lavage using small nasogastric tubes, except under special circumstances, is nonproductive and cannot be advocated. If it must be used, a large-bore orogastric hose should be used. Administration of activated charcoal prior to lavage should be considered. In situations in which prompt induction of emesis is not possible or contraindications to emesis exist, activated charcoal followed by, or mixed with, a cathartic (preferably sorbitol) should be used as an alternative to removal of gastric contents. Patients with significant symptoms from ingestion requiring hospitalization should receive repeat doses of charcoal and cathartic until symptoms resolve. Activated charcoal should be given in conjunction with other appropriate therapies. Although the data to substantiate this recommendation are limited, particularly in pediatric patients, it is a benign therapy that holds promise of increasing drug elimination.

Gastric emptying. Risk versus benefit in the treatment of acute poisoning

This review examines the various clinical options used to elicit gastric emptying, viz. drug-induced emesis, mechanical pharyngeal stimulation, gastric lavage, and catharsis. Apomorphine and syrup of ipecac are the 2 drugs most frequently used for induction of emesis. Both agents act centrally and, in addition, syrup of ipecac has a peripheral action. Toxins ingested or foods previously eaten may inhibit or enhance emetic action by interfering with mediating and conducting mechanisms. Studies indicate that both syrup of ipecac and apomorphine are similarly effective in inducing emesis; however, apomorphine has a shorter reaction time compared with syrup of ipecac. There are more risks involved with the use of apomorphine, since it causes central nervous system and respiratory depression. Syrup of ipecac has been shown to be relatively safe when used in its recommended dosage for emesis. However, several toxicities have been reported with the use of the fluid extract of ipecac. Emesis is contraindicated in patients who are obtunded or comatose, and in patients who have ingested stimulants, some hydrocarbons, or corrosives. Mechanical pharyngeal stimulation is a simple method of inducing emesis; however, it is often unsuccessful and rarely recovers a significant portion of the gastric contents. Gastric lavage is a procedure which has been relied upon for over a century. Its effectiveness is dependent on the nature, form, and dosage of the poison, latency between time of ingestion and lavage, and technique. In clinical experiments studying gastric lavage, it has been noted that the procedure is most beneficial 1 to 2 hours postingestion for the majority of poison ingestions. Lavage also provides an excellent route for activated charcoal and selected antidotes. Gastric lavage may pose several risks to the patient, including obstruction and contamination of the airways and oesophageal damage. Contraindications for gastric lavage are similar to those for emesis except that it may be safer to use in obtunded, comatose, or uncooperative patients. Cathartics used during initial poisoning therapy are usually the saline cathartics. They elicit an osmotic reaction in the small intestine which results in increased intraluminal fluid bulk, hyperperistalsis, and subsequent propulsion of contents. Cathartics have also been shown to stimulate the secretion of cholecystokinin, which is thought to have similar effects on the intestine. Cathartics have not been shown to significantly enhance drug elimination from the gastrointestinal tract.(ABSTRACT TRUNCATED AT 400 WORDS)

Ipecacuahana induced emesis in the treatment of self-poisoned adults

One hundred consecutive adult patients presenting to an Accident and Emergency Department following intentional self-poisoning were given 50 to 80 ml Paediatric Ipecacuahana Emetic Mixture BP as an emetic, together with two or three glasses of strong orange juice. A satisfactory emetic result was obtained in 99 patients. No toxic effects were noted in these patients, or in the one patient in whom emesis did not occur, and who subsequently refused gastric lavage. The potential toxicity of Ipecacuahana Syrup itself is discussed, and attention drawn to the lower Emetine content of Paediatric Ipecacuahana Emetic Mixture (BP), rather than that of the formulations used in previously published reports. The use of Paediatric Ipecacuahana Emetic Mixture B.P. in adults is effective and safe in this dosage.