II. Background
- Misuse is increasing in 2016-2018 and associated with Arrhythmia and Cardiac Arrest deaths
- Users refer to Imodium as "Poor-man's Methadone"
- Users take more than 64 mg (4 fold higher than the total daily dose) to get high
- Loperamide is highly albumin bound
- High doses saturate available albumin, and unbound Loperamide may cross the blood brain barrier
-
P-Glycoprotein prevents Loperamide from crossing blood-brain barrier (and also stimulates GI excretion)
- Abusers often coningest P-Glycoprotein Inhibitors (e.g. Cimetidine, Quinine) to enhance CNS effects
- References
- (2016) Presc Lett 23(7): 37-8
III. Signs
- Somnolence
- Respiratory depression
- Syncope
-
Cardiac Dysrhythmia
- See EKG below
IV. Labs
- Basic metabolic panel
- Serum Calcium
- Serum Magnesium
V. Diagnostics: Electrocardiogram
- Premature Ventricular Contractions
- QRS Widening may be significant (e.g. >160 ms)
- QTc Prolongation may be significant (e.g. >700 ms)
- Torsades de Pointes
VI. Management
- Consider Gastric Decontamination with Activated Charcoal
- Indicated for early presentation of massive ingestion (e.g. 1 mg/kg)
- CNS depression (including respiratory depression)
- Treat Arrhythmias
- Sodium Bicarbonate for QRS Widening
- QT Prolongation with risk of Torsades de Pointes
- See Torsades de Pointes for management
- Disposition
- Asymptomatic or improving patients discharged after 6 hours from time of ingestion
- Admit patients with Dysrhythmias or other significant findings
VII. References
- Lasoff (2016) Crit Dec Emerg Med 30(12): 24
- Swadron and Nordt in Herbert (2016) EM:Rap 17(1): 3
- Swadron and Nordt in Herbert (2018) EM:Rap 18(6): 8
- Eggleston (2017) Ann Emerg Med 69(1):83-6 +PMID:27140747 [PubMed]