Washington News: Ongoing Controversy Re: Syrup of Ipecac

January 1, 2006 3:55 pm Topics: Over the counter

Published in the January 2006 Washington State Board of Pharmacy Newsletter

By William O. Robertson, MD, Medical Director, Washington Poison Center

When Poison Centers first appeared in the mid-1950s, they focused almost exclusively on the problems of children who took “over-the-counter” medications and “household products.” Adult calls began in the 1960s and account for less than half the calls even today.

In those early days, “stomach pumping” (gastric lavage via a nasogastric tube that had to be inserted at the hospital emergency room [ER]) was the favored method to try to decontaminate the stomach of ingested poisons. By the early 1960s, however, a number of “controlled trials” confirmed that induction of emesis by use of apomorphine or by Syrup of Ipecac (SOI) leads to bigger returns, especially in children. By the late 1960s just as home placement and use of SOI was catching on, emergency physicians were popularizing the use of activated charcoal that, again, had to be administered in the ER. At the time, it averaged 69 minutes to get to the hospital and even longer to get the charcoal down.

Over the intervening years, the debate has continued. Today, however, all agree that time lapse until treatment is the dominant variable when it comes to determining effectiveness – as opposed to the technique of decontamination. Almost no adults are able to be treated quickly, but 80% of children less than six years of age are recognized by parents as having taken something “bad” in less than 10 minutes. Home treatment with SOI can be completed in as little as 30 minutes, definitely less than an hour. And more and more ingestions can be classified as “non-toxic” over the phone, particularly for the children. The result is that induction of emesis at home for children has fallen from 30% in the 1970s to less than 5% today. Despite that reduction, Poison Centers still urge that a bottle of SOI be kept in the home. Since the 1980s, the Board of Pharmacy has required that retail pharmacies stock some SOI to ensure its easy availability.

In 2003 the American Academy of Pediatrics (AAP) chose to abandon its almost 40 years of endorsement of using SOI at home. The American Association of Poison Control Centers declined to support the AAP’s move. As a result, parents and pharmacists were caught in the middle as to what to do. Since 2004, we at the Washington Poison Center have had increasing calls from parents stating that they had been unable to obtain SOI after we had urged its use. At our request, the Board investigated the matter and confirmed that at least four commercial suppliers are able to provide wholesale SOI, and then it encouraged pharmacies to follow the Board’s long-standing position on SOI.

Meanwhile, we at the Poison Center, and poison centers elsewhere, had re-examined the data about delays until treatment and found that using charcoal in the hospital ER still consumes far too much time. We strongly favor home use of SOI, particularly for the toddlers. SOI is quicker, far less expensive, far more convenient, and avoids the risks of those rides to get to the hospital.
[Note: WAC 246-869-200, Poison Control, still requires each pharmacy to maintain at least a one-ounce bottle of SOI in stock at all times.]