Loperamide abuse cardiotoxicity. Should loperamide still be an over the counter medication?

Loperamide is an over-the-counter anti-diarrheal medication that is inexpensive, easily accessible, and widely used. It is generally thought to be safe and effective without the potential for abuse. However, recent discovery of its ability to treat opioid withdrawal symptoms at high doses has led to not only its abuse, but also the need to recognize its cardiotoxicity due to the ability to prolong the QTc interval. We report a case of a 33 year old female with a history of opioid dependence who presented to the emergency department with acute onset shortness of breath and generalized weakness who was subsequently found to be in ventricular tachycardia. Electrocardiogram showed prolongation of the QTc and the patient later admitted to ingestion of 70 loperamide pills daily for the past year in order to alleviate her opioid withdrawal symptoms. Due to increased loperamide abuse and toxicity displayed within the last several years, public and health provider awareness should be optimized to fully understand its lethality, and stricter regulations on its availability to the general population should be considered. Even in asymptomatic patients with ECG abnormalities, emergency medicine physicians should admit them for further monitoring and aggressive medical therapy.