Managing acute toxicity from nonprescription stimulants

The symptomatology and management of toxicity caused by nonprescription stimulants is reviewed. Nonprescription stimulants contain (singly or in combination) the same basic active ingredients: caffeine 100-200 mg, phenylpropanolamine 25-50 mg, and ephedrine 25 mg. Generally, toxic reactions involve excessive CNS stimulation (e.g., increased motor activity, anxiety, and agitation) and mildly elevated pulse rate and blood pressure that resolve in six to eight hours without specific treatment. However, reactions following the ingestion of these stimulants have included severe hypertension, possible renal failure, cerebral hemorrhage, and cardiac arrhythmias. Neither ephedrine nor caffeine ingested as single entities have been reported to produce increases in blood pressure associated with end-organ damage; however, severe hypertension has followed therapeutic doses of phenylpropanolamine. General management in the overdosed patient involves establishing respiration, initiating emesis, administering activated charcoal and a cathartic, and monitoring the patient's blood pressure, ECG, fluid intake, and urinary output. The increased availability of tablets and capsules containing substantial quantities of phenylpropanolamine, caffeine, and ephedrine creates a potential for drug-induced morbidity and mortality.