Ipecac Syrup-Induced Emesis…No Evidence of Benefit

For decades, ipecac syrup-induced emesis had been the cornerstone of managing patients who ingested a potential poison. However, the use of this panacea has plummeted significantly over the last 20 years and by nearly 400% since 1997 when the American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) published a joint position statement on ipecac syrup which concluded that ipecac does not have a positive impact on patient outcome 1. The ipecac statement was revised in 2004 as a position paper and arrived at the same conclusions 2. Furthermore, the American Academy of Pediatrics (AAP) published a policy statement in 2003 that affirmed "…ipecac should no longer be used routinely in the home… 3." Both the AACT/EAPCCT and AAP positions were based on evidence that ipecac syrup does not change patient outcome. These position and policy statements were not new revelations, but consistent with the admonitions that were published previously about the therapeutic effectiveness of ipecac syrup.

In 1981 Dershewitz and Niederman published "Ipecac at home—a health hazard?" and stated that "The ipecac story is but another example of a seemingly sensible preventive health strategy being universally recommended and widely established before its efficacy and validity has been established 4." Kulig, et al. published their landmark clinical research paper in 1985 that concluded "Syrup of ipecac did not significantly alter the clinical outcome of patients who were awake and alert on presentation to the emergency department… 5." Similarly, in 1986 Vale and colleagues published an editorial on ipecac and concluded that "Although its use may satisfy the innate desire of parents, doctors, and nursing staff to ‘do something’, there is no evidence that it prevents drug absorption or systemic toxicity 6." However, American health care professionals and especially poison centers failed to heed that advice and during the same time period up to 15% of poisoning exposure patients were treated with ipecac syrup 7! In contrast, an unpublished informal survey of international poison centers that was conducted by the American Association of Poison Control Centers in 2001, revealed that only one of the 28 responding centers indicated that they would use ipecac and only in rare circumstances (toxic ingestion of acetaminophen) [Personal communication. Anthony S. Manoguerra, September 16, 2004]. Most of us were strong advocates of ipecac use, but we deviated from mainstream international toxicology and the evidence base, because we failed to ask a fundamental question: does ipecac change patient outcome?

The science does not support the use of ipecac under any circumstance. The effectiveness of ipecac has not been studied in adequate clinical trials. The volunteer studies focused on the removal of marker substances but there was wide variability in the results and by 30 minutes post-ingestion, emesis was no better than the control groups. The clinical studies were fraught with methodological flaws that made it difficult to extrapolate the results to patient outcome. While there are always those who would suggest that the absence of evidence does not mean that ipecac is without merit, that is not a valid argument in contemporary evidence-based medicine. In essence, there are no data that demonstrate a positive outcome following the use of ipecac in either the pre-hospital or hospitalized patient who has ingested a poison.

Many poison centers have abandoned the use of ipecac entirely, but at least one center reported its use in 7% of their cases in 2003 8. However, there is a growing consensus among poison centers that ipecac has little or no role to play in the management of the poisoned patient—in 2003 only 0.4% of the patients received ipecac syrup (not recommended by the poison center in the majority of reports) and most recently, U.S. poison centers have recommended ipecac syrup in only about 50 cases (approximately 0.03%) per month 8! Even this very limited use of ipecac syrup is not supported by evidence that it has an impact on patient outcome. Yet, some toxicologists and poison centers continue to recommend the use of ipecac syrup to minimize toxicity and health care facility referral through home treatment. Still others have justified the use of ipecac by suggesting that people living in remote areas may benefit from having ipecac available and this may fulfill the ‘rare’ indication. In fact, the ipecac recommendation rate from poison centers in frontier counties (6.18/1000 pediatric exposures) is less than in non-frontier counties (8.51/1000 pediatric exposures) 9.

Contemplate this question: if ipecac syrup was being considered today as a new drug for use in the poisoned patient, would it be approved? The undeniable answer is no, since there is no evidence that ipecac use in the poisoned patient changes outcome. Given the lack of any evidence to support the use of ipecac, it is unclear how the consensus panel publication ("Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons") in this issue of the Journal, arrived at the conclusion that "…ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations…"? What are the rare circumstances? None were elucidated in the guideline and the consensus panel concluded that individual practitionersand poison centers were the most qualified to determine when ipecac might be useful. The evidence tables were elegant and more extensive than the previously published statements by the AACT/EAPCCT and the AAP. However, the consensus panel failed to provide any guidance with regard to a single rare indication for using ipecac syrup. That body of evidence does not exist in the scientific literature.

Ipecac produces emesis, but that is the extent of the evidence. There is no basis for the recommendation that ipecac may be useful in rare circumstances. The use of ipecac syrup should be abandoned and the conclusions of this guideline should be disregarded. At a time when the use of ipecac has been eroded to near extinction, the glimmer of rare indications for ipecac use gives life to a treatment that has never been validated.

Edward P. Krenzelok, Pharm.D., F.A.A.C.T., D.A.B.A.T.

Director, Pittsburgh Poison Center

Children's Hospital of Pittsburgh

Professor Pharmacy and Pediatrics

University of Pittsburgh