Tianeptine toxicity

Background

  • Tianeptine is an atypical antidepressant that has different effects on multiple neurochemicals and receptors including serotonin, glutamate, NMDA, and opioid
  • Full μ-opiod receptor agonism can lead to effects similar to opioid toxicity and overdose
  • From 2014-2017 the USA saw a large increase in reported cases of tianeptine toxicity thought to be due to the discovery of its opioid effects and its ability to induce euophoria; it can be purchased online as a dietary supplement or research chemical[1][2]
  • Not FDA approved in the USA, still used in other countries as a treatment for depression

Clinical Features

Differential Diagnosis

Sedative/hypnotic toxicity

Toxidrome Chart

Finding Cholinergic Anticholinergic Sympathomimetic Sympatholytic^ Sedative/Hypnotic
Example Organophosphates TCAs Cocaine Clonidine ETOH
Temp Nl Nl / ↑ Nl / ↑ Nl / ↓ Nl / ↓
RR Variable Nl / ↓ Variable Nl / ↓ Nl / ↓
HR Variable ↑ (sig) Nl / ↓ Nl / ↓
BP Nl / ↓ Nl / ↓
LOC Nl / Lethargic Nl, agitated, psychotic, comatose Nl, agitated, psychotic Nl, Lethargic, or Comatose Nl, Lethargic, or Comatose
Pupils Variable Mydriatic Mydriatic Nl / Miotic
Motor Fasciculations, Flacid Paralysis  Nl Nl / Agitated Nl
Skin Sweating (sig) Hot, dry Sweating Dry
Lungs Bronchospasm / rhinorrhea Nl Nl Nl
Bowel Sounds Hyperactive (SLUDGE) ↓ / Absent Nl / ↓ Nl / ↓
^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan
Withdrawal from substances have the opposite effect

Evaluation

  • Mainly a clinical diagnosis
  • Assess airway first to determine need for intubation
  • POC glucose
  • EKG - look for widened QRS, prolonged QTc
  • Basic labs
  • Urine tox screen


Management

  • Airway management
  • Oxygen for hypoxia
  • Naloxone has been successfully used to treat at least one case in the literature but data is limited[3]
  • Benzodiazepines for agitation

Disposition

  • Depends on severity of toxicity
    • Admit to floor vs ICU

See Also

External Links

References

  1. Zahran et al. Characteristics of Tianeptine Exposures Reported to the National Poison Data System – United States 2000-2017. MMWR Morb Mortal Wkly. Rep 2018;67:815-818. DOI: http://dx.doi.org/10.15585/mmwr.mm6730a2external icon.
  2. Bakota EL et al. Case Reports of Fatalities Involving Tianeptine in the United States. Journal of Analytical Toxicology. 2018 Sep;42(7):503-509. DOI: 10.1093/jat/bky023.
  3. Ari M, Oktar S, Duru M. Amitriptyline and tianeptine poisoning treated by naloxone. Hum Exp Toxicol. 2010;29(9):793-795. doi:10.1177/0960327110372403