(932) Uncharted Waters: A Case Report on Neptune’s Fix Elixir Overdose

Introduction: Neptune’s Fix Elixir is a non FDA approved substance that has become increasingly popular for the management of pain, anxiety and depression. The primary active ingredient, tianeptine, is an atypical TCA, which acts as a glutamate modulator and opioid agonist. Given its euphoric effects, high abuse potential, and unregulated distribution at small retailers (commonly gas stations), Neptune’s Fix has been given the nickname “gas-station heroin.” Overdoses are becoming increasingly common, in which symptoms include hypertension, tachyarrhythmias, hallucinations, seizures, coma, and death.

Description: We present the case of a 54 year old female with PMH of COPD and BP disorder, who presented to the ED via EMS with AMS after ingesting an unspecified amount of Neptune’s Fix. The patient’s boyfriend reported she had ingested the majority of the 10cc bottle, aside from a small sip which he initially took. Following ingestion, she became increasingly lethargic and was obtunded when EMS arrived. Naloxone was administered with no improvement. Upon arrival at the ED, the patient was intubated for airway protection and admitted to the ICU. She was found to be in new-onset AFib RVR, requiring a diltiazem drip. Urine toxicology was positive for benzos and opiates, consistent with home meds. Poison control was contacted and recommended treating like a TCA overdose with telemetry monitoring and serial EKGs to monitor the QRS and QTc intervals - both of which remained within normal limits (QRS < 100ms and QTc < 500ms). Diltiazem drip was weaned over 2 days and transitioned to PO rate control medication. The patient was extubated, downgraded, and ultimately discharged in stable condition.

Discussion: Given its increasing popularity, ease of access, and undetectability on routine toxicology screening, it is essential to consider tianeptine when evaluating patients for suspected overdose. Due to TCA-like effects, close monitoring of vitals and serial EKGs is critical to prevent seizures and potentially lethal cardiac arrhythmias. To spread awareness and prevent future overdoses, healthcare professionals should report adverse events related to the use of this product to the FDA's MedWatch Safety Information and Adverse Event Reporting Program.