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Cephaelis ipecacuanha (Brot.) A. Rich
Related species commonly used interchangeably or in a mixture is Cephaelis. acuminata (Benth.) Karst. (Rubiaceae)

Synonyms
Cephaelis ipecacuanha: Callicocca ipecacuanha Brot., Cephaelis emetica Pers., Evea ipecacuanha (Brot.) Standl., Ipecacuanha offi cinalis (Brot.) Farw., Psychotria emetica Vell., P. ipecacuanha (Brot.) Muell. Arg. (also Stokes), Uragoga emetica Baill., U. ipecacuanha (Willd.) Baill. (3, 8, 10). Cephaelis acuminata: Psychotria acuminata Benth., Uragoga acuminata (Benth.) O. Kuntze, U. granatensis Baill.

Local names
Ark ad dhahab, Brazilian ipecac (= Cephaelis ipecacuanha (Brot.) A. Rich.), Cartagena ipecac (= Cephaelis acuminata (Benth.) Karst.), Cartagena ipecacuanha, ipeca, ipecac, ipecacuanha, ipecacuana, jalab, Kopfbeere, matto grosso, mayasilotu, Nicaragua ipecac (= Cephaelis acuminata (Benth.) Karst.), poaia, raicilla, raizcilla, Rio ipecac (= Cephaelis ipecacuanha (Brot.) A. Rich.), togeun

Description
Cephaelis ipecacuanha: A low straggling shrub. Underground portion consists of a slender rhizome bearing annulated wiry roots and slender smooth roots. Rhizome arches upwards and becomes continuous with a short, green, aerial stem bearing a few opposite, petiolate, stipulate, entire, obovate leaves. Flowers small, white and capitate, occurring in the leafaxils; corolla infundibuliform. Fruits are clusters of dark purple berries, each containing two plano-convex seeds.
Cephaelis acuminata: Resembles Cephaelis ipecacuanha, but has a root with less pronounced annulations

Plant material of interest
dried roots and rhizomes

Chemical assays
Contains not less than 2% of total alkaloids calculated as emetine, determined by titration. Assay for emetine and cephaeline by column chromatography plus spectrophotometry. A high-performance liquid chromatography method is also available

Major chemical constituents
The major active constituents are isoquinoline alkaloids (1.8–4.0%), with emetine and cephaeline accounting for up to 98% of the alkaloids present. Content in Cephaelis ipecacuanha: emetine 60–70%, cephaeline 30–40%; in Cephaelis acuminata: emetine 30–50%, cephaeline 50–70%. A 30-ml dose of ipecac syrup contains approximately 24 mg of emetine and 31 mg of cephaeline. Other alkaloids of note are psychotrine, O-methylpsychotrine and ipecoside

Medicinal uses
Uses supported by clinical data
A syrup made from the roots is used as an emetic, to empty the stomach in cases of poison ingestion.

Uses described in pharmacopoeias and well established documents
See Uses supported by clinical data

Uses described in traditional medicine
Treatment of parasites, the common cold and diarrhoea. Also to stimulate uterine contractions and induce abortion.

Proven pharmacological activity
Animal studies
Emetic

Human studies
Emetic

Adverse reactions
Large doses of Radix Ipecacuanhae have an irritant effect on the gastrointestinal tract, and may induce persistent bloody vomiting or diarrhoea. Mucosal erosions of the entire gastrointestinal tract have been reported. The absorption of emetine, which may occur if vomiting is not induced, may give rise to adverse effects on the heart, such as conduction abnormalities or myocardial infarction. These, in combination with dehydration, may cause vasomotor collapse followed by death. Chronic abuse of the roots to induce vomiting in eating disorders has been implicated in the diagnosis of cardiotoxicity and myopathy due to the accumulation of emetine. Adverse effects of repeated vomiting, such as metabolic complications, aspiration pneumonitis, parotid enlargement, dental abnormalities, and oesophagitis or haematemesis due to mucosal lacerations may be observed. Cardiovascular toxicity, manifesting as muscle weakness, hypotension, palpitations and arrhythmias, may occur. Death was reported f or one subject who had ingested 90–120 ml of a syrup prepared from the roots per day for 3 months. Prolonged vomiting has been reported in 17% of patients given the roots for the treatment of poisoning, which may lead to gastric rupture, Mallory-Weiss lesions of the oesophagogastric junction, cerebrovascular events, pneumomediastinum and pneumoperitoneum. Allergy to the roots was reported after inhalation of powdered roots, characterized by rhinitis, conjunctivitis and chest tightness. There have been a number of deaths reported in small children due to an overdose owing to the substitution of 10.0–60.0 ml of a fl uidextract of the roots for a syrup prepared from the roots. It is believed that the fl uidextract was mistaken for the syrup. The fl uidextract is 14 times more potent than the syrup. Other adverse reactions to the roots include severe diarrhoea, nausea and abdominal cramps

Contraindications
While emesis is usually indicated after poisoning resulting from oral ingestion of most chemicals, emesis induced by Radix Ipecacuanhae is contraindicated in the following specifi c situations: following ingestion of a corrosive poison, such as strong acid or alkali; when airway-protective reflexes are compromised, for example in patients who are comatose or in a state of stupor or delirium; following ingestion of a central nervous system stimulant, when vomiting may induce convulsions; in cases of strychnine poisoning; or following ingestion of a petroleum distillate. Radix Ipecacuanhae has been used as an abortifacient in traditional medicine and its use is therefore contraindicated during pregnancy.

Warnings
Numerous deaths have occurred owing to the administration of a fluid extract of Radix Ipecacuanhae instead of a syrup prepared from the roots. The fluid extract is 14 times stronger than the syrup and should never be administered as a substitute for the syrup.

Precautions
General
Radix Ipecacuanhae should not be used as an emetic in patients whose condition increases the risk of aspiration or in patients who have taken substances that are corrosive or petroleum products that may be dangerous if aspirated. The roots should not be given to patients in shock, at risk of seizure, or with cardiovascular disorders.

Drug interactions
The emetic action of the roots may be delayed or diminished if given with or after charcoal. Concomitant administration of milk was believed to reduce the effi ciency of emesis induced by the roots. However, no signifi cant differences in the time to onset of vomiting, the duration of vomiting, or the number of episodes were observed in 250 children who were given a syrup prepared from the roots with milk compared with 250 children given the syrup with clear fluids. Decreases in the absorption of paracetamol, tetracycline and aminophylline were observed after concomitant administration of 20.0 ml of an aqueous extract of the roots.

Carcinogenesis, mutagenesis, impairment of fertility
An aqueous extract of the roots, 50.0 µg/ml, was not mutagenic in the Salmonella/microsome assay in S. typhimurium strains TA98 and TA100. The mutagenicity of a fluid extract of the roots was evaluated in the Salmonella/microsome assay, the chromosomal aberration test in cultured Chinese hamster lung cells and the mouse bone marrow micronucleus test (oral administration). No mutagenic effects were observed.

Pregnancy: non-teratogenic effects
See Contraindications.

Paediatric use
Do not exceed recommended doses. Do not give the fluid extract to children. For children up to 6 months of age, the syrup should only be administered under the supervision of a physician

Other precautions
No information available on precautions concerning drug and laboratory test interactions; teratogenic effects during pregnancy; or nursing mothers.

Dosage forms
Dried roots and rhizomes, liquid extracts, fluid extract, syrup and tincture. Dried roots and rhizomes should be stored in a tightly sealed container, protected from light.

Posology
(Unless otherwise indicated)
As an emetic in cases of poisoning other than corrosive or petroleum based products. Doses should be followed by ingestion of copious volumes of water. Doses may be repeated once, 20–30 minutes after the initial administration, if emesis has not occurred. Adults: Ipecac Syrup, 15–30 ml (21–42 mg total alkaloids). Children: 6 months–1 year, 7–14 mg of total alkaloids (5–10 ml) of Ipecac Syrup; older children, 21 mg of total alkaloids represented in 15 ml Ipecac Syrup

 

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