(1432) Neptune’s Fix: Tianeptine Cannabinoid Hyperemesis Syndrome Resulting in Severe Metabolic Alkalosis

Introduction: Tianeptine is an atypical tricyclic antidepressant with mu and delta opioid agonist activity that is used in other countries for depression and irritable bowel syndrome (IBS) but is not approved for use in the United States (US). Recently, it has been shown to have additional synthetic cannabinoid receptor agonist activity. We report a tianeptine-induced cannabinoid hyperemesis syndrome resulting in nausea and vomiting causing metabolic alkalosis and renal failure.

Description: A 32-year-old male with no past medical history presented to the emergency room with a chief complaint of confusion. He was accompanied by his father, who stated that the patient had been vomiting and was confused. The father reported that he had been using ‘Neptune’s Fix Elixir’ over the counter. Patient was communicative but confused. Initial laboratory values were significant for a pH of 7.823, a pCO2 of 26.8mmHg, an HCO3 of 44mmol/L, a sodium of 120mmol/L, a potassium of 2.8mmol/L, a chloride < 50 mmol/L, CO2 >40mmol/L, BUN >209mg/dL, serum creatinine 6.38mg/dL, and a lactic acid of 4.8mmol/L. Patient’s volatile panel was negative but his urine drug screen was positive for fentanyl. Patient was treated with six days of ampicillin-sulbactam for aspiration pneumonia, multiple liters of isotonic fluid, electrolyte repletion, and supportive care with rapid correction of his alkalosis and confusion. He was discharged home in stable condition.

Discussion: Tianeptine is an atypical tricyclic antidepressant with full mu and delta opioid agonist activity that is sold online and at small retail stores despite lack of Food and Drug Administration (FDA) approval. It has recently been shown to have synthetic cannabinoid receptor agonist activity. In this case, we suspect that tianeptine ingestion resulted in cannabinoid hyperemesis syndrome causing intractable nausea and vomiting, causing a severe metabolic alkalosis that quickly resolved with fluid administration and supportive care. It is important to note that tianeptine is unregulated and sold under multiple names (Neptune’s Fix, Pegasus, and Zaza) and may be unknowingly altered with unknown substances, producing adverse clinical effects.