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Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

10.1097/MS9.0000000000000170
00048
3
Short Communications
Rising toxicity of the antidiarrheal drug: loperamide in Pakistan
http://orcid.org/0000-0001-5421-0212
Habib Ashna MBBS ashnahabib937@gmail.com

http://orcid.org/0000-0001-8028-9841
Mahfooz Arisha MBBS arishamahfooz862@gmail.com

http://orcid.org/0000-0001-8082-9449
Nazir Zainab MBBS zainabnazir42@gmail.com

Dow University of Health Sciences, Karachi, Pakistan
* Corresponding author. Address: Dow University of Health Sciences, Karachi 75800, Pakistan. E-mail address: ashnahabib937@gmail.com (A. Habib).
3 2023
17 2 2023
85 3 569570
3 11 2022
25 12 2022
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Loperamide, an opioid-based anti-diarrheal drug, frequently purchased without a prescription over-the-counter in Pakistan, the majority of the community thinks it is safe to use. It has been speculated that loperamide toxicity is greatly underreported since it is not frequently included in drug screening. The Pakistani government has to reevaluate its loperamide over-the-counter regulations. By media campaigns, the general population of Pakistan should be made aware of the risky consequences of high doses of loperamide.

Keywords:

loperamide
anti-diarrheal drug
loperamide toxicity
opioid based drug
OPEN-ACCESSTRUE
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pmcLoperamide is an opioid-based antidiarrheal medication marketed under the brand name ‘Imodium’. Due to its powerful mu opioid receptor agonist effects, it received US Food and Drug Administration approval in 1976 to be used in the United States for the treatment of acute and chronic diarrhea when taken in accordance with the recommended dosage, which is not to exceed 16 mg daily1. The general population of Pakistan believes that loperamide is safe to use since it is often acquired over-the-counter without a prescription. Extremely large dosages are used illicitly to get high and as a form of self-medication to ease the withdrawal symptoms from opioids in Pakistan. The US Food and Drug Administration suggested that pharmaceutical companies voluntarily limit the loperamide package size for the benefit of the general public because high doses of loperamide do carry a risk of catastrophic cardiac events2. Despite the fact that male respondents were more likely to actively abuse the medication, female users of loperamide were more prevalent in reported suicide attempts3. A 36-year-old male was found unconscious at work and sent to the hospital with a tenuous history of loperamide abuse4. The episode highlights the importance of a possibly lethal side effect of this widely available, bulk-purchasing medicine. In 2021, a young man with seizures and recurrent bouts of polymorphic ventricular tachycardia presented to the Emergency Room5. According to an examination of his medical history, he had been taking more than 100 loperamide tablets daily for the past 12 months5. Both of these instances from Pakistan demonstrate that loperamide toxicity is still an issue there and will get worse if it is not addressed soon. Considering the new centers of disease control and prevention guidelines, which will make it more difficult for patients to get opioid prescriptions, we believe that usage of loperamide as a substitute will increase. Because loperamide is not often included in drug screening, it has been hypothesized that loperamide toxicity is significantly underreported. We suggest that individuals who experience syncope or cardiac dysrhythmias while abusing opioids or who are already using loperamide have an empirical quantitative loperamide drug screen. Clinicians must always be on the lookout for loperamide misuse in the appropriate setting, and they must diligently report any new instances of loperamide’s usage as a cardiac toxin. To prevent the catastrophic effects of loperamide misuse, it is imperative to raise public awareness of the toxicity of loperamide and to recognize loperamide abuse as a significant cause of cardiac dysrhythmias and syncope. Every time a prescription is provided, patients need to be made aware of overdosing and its effects. To prevent risk-taking, more caution should be used while delivering it. The Pakistani government should reconsider its over-the-counter loperamide policy. The general public of Pakistan should be made aware of the hazardous effects of excessive doses of loperamide through media campaigns.

Ethical approval

No ethical approval required for this paper.

Consent

This study was not done on patients therefore no written consent was required.

Sources of funding

None funding source.

Author contribution

A.H., A.M., Z.N.: conception of study, major drafting of work, literature search, final approval, and agreeing to the accuracy of work.

Conflicts of interest disclosure

Authors state no conflict of interest.

Research registration unique identifying number (UIN)

1. No patients were included.

2. Name of the registry: NA.

3. Unique identifying number or registration ID: NA.

4. Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.

Guarantor

Ashna Habib.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 17 February 2023
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References

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2 US Food and Drug Administration 2019. FDA limits pachaging for anti-diarrhea. Accessed 30 October 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-use
3 Vakkalanka JP Charlton NP Holstege CP . Epidemiologic trends in loperamide abuse and misuse. Ann Emerg Med 2017;69 :73–8.27823872
4 Ali Z Shoukat U Khan M . Loperamide overdose induces ventricular tachycardia with catastrophic outcomes. J Commun Hosp Intern Med Perspect 2020;10 :229–32.
5 Iqbal S Fayyaz SM Saeed Y . Loperamide-induced cardiotoxicity: a case overlooked? BMJ Case Rep 2021;14 :e243325.
