Toxicity of weight loss agents.

INTRODUCTION: With the rise of the obesity epidemic in the United States over the last several decades and the medical complications seen with it, weight loss and dieting have become a national public health concern. DISCUSSION: Because of their increased use and availability through internet sales, several different dieting agents were reviewed for potential toxicity. These included: syrup of ipecac, cathartics, human chorionic gonadotropin hormone, 2,4 Dinitrophenol, guar gum, phenylpropanolamine, ma huang/ ephedra, caffeine, clenbuterol, fenfluramine, sibutramine, thyroid hormone, orlistat and cannabinoid antagonists. CONCLUSIONS: With the internet making even banned products readily accessible, healthcare providers need to be aware of the potential toxicities of a wide range of weight loss agents. Our review covered topics we thought to be most historically significant as well as pertinent to the practice of medical toxicology today.

A study of intragastric and intravesicular pressure changes during rest, coughing, weight lifting, retching, and vomiting.

BACKGROUND: In patients undergoing a variety of procedures, surgical success is in part dependent on maintaining normal intra-abdominal pressure in the immediate postoperative period. Our objective was to quantify intragastric and intravesicular pressures during activities, through the use of manometry catheters. METHODS: Ten healthy volunteers had a manometry catheter placed transnasally, and a urinary Foley catheter placed. Baseline intragastric and intravesicular pressures were recorded and the catheters were then transduced continuously. Pressures were recorded with activity: coughing, lifting weights, retching (dry heaving), and vomiting. RESULTS: All pressure changes were significant from baseline except for weight lifting. The highest intragastric pressure was 290 mmHg, seen during vomiting. Comparison of intragastric and intravesicular pressures showed no significant difference. There was significantly higher intragastric pressure with vomiting and retching as compared with coughing, whereas coughing applied more pressure than weight lifting. CONCLUSIONS: This is the first report of intragastric pressures during vomiting and retching (dry heaving). We conclude that vomiting and retching (dry heaving) can render significant forces on any tissue apposition within the stomach or the peritoneal cavity.

Ipecac syrup abuse, morbidity, and mortality: isn't it time to repeal its over-the-counter status?

PURPOSE: To review and address the abuse of ipecac, describing its epidemiology, toxicity, clinical characteristics, and laboratory assessment. METHODS: A Medline search (1980-2003) for Ipecac abuse and Ipecac toxicity, n = 34. RESULTS: Ipecac abuse occurs predominantly among adolescent and young adult females who are either experimenting with purging or have an eating disorder. Psychiatric comorbidity is common. Death can occur and is usually of cardiac origin. Morbidity includes myocarditis with arrhythmias, myositis, gastroesophageal pathology, including Mallory Weiss tears, diarrhea, and metabolic abnormalities (alkalosis, hypokalemia, dehydration). The injuries can reverse with cessation of ipecac use. A high index of suspicion is needed for early detection. Classic findings are abnormal EKG and echocardiography and/or elevation of muscle enzymes (CPK, adolase). Emetine, the alkaloid in ipecac, can be confirmed in serum, urine, and tissue by high performance liquid chromatography. CONCLUSIONS: Ipecac abuse is dangerous, even deadly. However, if abuse is discontinued, cardiac and muscle damage tends to reverse. Were ipecac syrup to remain an over- the-counter medication, or become a prescription medication, more stringent warning labels ought to be included and further education be provided about its toxicity and potential for abuse. Removing ipecac from the over-the-counter category would best eliminate its potential for abuse.

Vomiting induction by ipecac syrup in dogs and ferrets.

The dog has been used as an experimental animal in emesis research. In this study, we analyzed the emetic effects of ipecac syrup using a smaller animal, the ferret, and compared its response to that of the dog. Dogs and ferrets were divided into 4 groups (n = 4, each). Each group was given either 0.1, 0.25, 0.5, or 1.0 ml/kg of ipecac syrup, and the latency and numbers of retching and vomiting were recorded. Animals given an equal volume of saline served as controls. The numbers of vomiting and retching increased dose-dependently in both dogs and ferrets, and there was no difference in latency and numbers of vomiting between them. The numbers of retching were greater in ferrets than in dogs at > or = 0.25 ml/kg. Taking these results into consideration, the ferret seems to be as useful as the dog in studies on emetic effects of ipecac syrup.

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.

Poison exposures and use of ipecac in children less than 1 year old.

Poison exposures in children less than 1 year old and the safety and efficacy of syrup of ipecac in children 9 to 12 months old were evaluated in a prospective eight-month study conducted at the Massachusetts Poison Control Center. Poison exposures in children less than 1 year old represented approximately 9% of the 38,080 calls received. Mobile children (in walkers, crawling, or walking) were at the greatest risk of poisoning. The majority of children (94%) were asymptomatic and none were hospitalized or died. The products involved were primarily plants (38%) and household products (30%). All 21 patients, ages 9 to 12 months, were given 10 mL syrup of ipecac under medical supervision and vomited within one hour. The mean time to vomit was 21.7 (SEM +/- 2.8) minutes. The patients vomited 3.3 (SEM +/- 0.3) times and all episodes of vomiting abated by 26.4 (SEM +/- 6.6) minutes. No significant side effects were noted. The use of the syrup of ipecac in the 9- to 12-month-old child appears to be safe and effective.

Syrup of ipecac in children less than one year of age.

A prospective study was conducted to determine if children less than one year of age developed any complications from syrup of ipecac-induced emesis. All patients in the study were derived from cases received by the poison center. Syrup of ipecac (10 ml) was administered with clear fluids to 24 children less than twelve months of age (mean age 8.7 months; median age 9.0 months; range 3.0-12.0). The average time for the onset of emesis was 26.10 minutes. All children vomited with a single dose of syrup of ipecac. No adverse sequelae such as aspiration or prolonged episodes of emesis were observed. Contrary to the popular belief that emesis may be contraindicated in children less than twelve months of age, we believe that emesis can be safely induced in the home setting in these young children.

Ingestions considered nontoxic.

The authors have compiled a list of common household products and drugs that are frequently ingested by children and may be considered nontoxic unless taken deliberately or in large amounts. An understanding of the nontoxic ingestion should prevent overtreatment and decrease emergency room visits.

PIP: In 1980, the National Clearinghouse for Poison Control Centers (NCPCC) received 126,000 reports from Poison Control Centers, but the true incidence of ingestions was actually much higher. Only 1 in 50 ingestions may be reported, indicating that the majority of ingestions are innocuous. 70% of reported episodes occurred in children under 5 years of age. Nontoxic ingestions occur when a victim consumes a nonedible product that usually does not produce symptoms. No product is entirely safe and all can produce symptoms if a large enough concentration is consumed. Knowledge of nontoxic ingestions helps avoid overtreatment and its risks and serves as a warning of inadequate supervision or an improper and unsafe environment. The designation of nontoxic ingestion has 6 criteria: 1) absolute identification of the product 2) absolute assurance that only 1 product was ingested 3) no signal word (danger, poison, warning, caution) on the container 4) a good approximation of the amount ingested 5) assurance that the victim is free of symptoms and 6) the ability to call back at intervals to determine that no symptoms have developed. A good rule of thumb for the average drug that 5 times the therapeutic dose may be a toxic dose; opiate narcotics are the exception and require medical observation because of their narrow margin of safety. There are several points to consider in deciding wheter to decontaminate the gastrointestinal tract, including the toxicity of the ingested agent, the amount ingested, the elapsed time since ingestion, and the presence of symptoms. Emergency room referral is mandatory in case of exposure to highly toxic agents, of a dose sufficient to lead to anticipation of servere symptoms, of manifestations of toxic exposure such as alterations in vital signs already present, or of a history of intentional ingestion. A detailed discussion of frequently ingested nontoxic household items and related items that may be toxic includes writing and art materials, toiletries and laundry agents, deordorizers and disinfectants, tobacco and matches, medicinals, pesticides and insecticides, miscellaneous substances, petroleum distillate hydrocarbons, and plants. Hormonal contraceptives have been reported to produce almost no toxicity. A 1962-65 report from the NCPCC of 962 ingestions listed only 40 producing nausea nd vomiting even after consumption of 21 pills. An iron additive could make the ingestion toxic for iron.