TOXICOLOGY QUESTION OF THE WEEK
JUNE 10, 2022
WHAT IS ZA ZA RED?
In 2017, the Question of the Week (May 16, 2017) discussed a new drug about which the poison center had been receiving calls: tianeptine. Tianeptine is reportedly the primary ingredient in a product sold under the name, Za Za Red.
Tianeptine is an atypical tricyclic drug that is used in Europe and Latin America but is not approved in the United States by the Food and Drug Administration (FDA). It is controlled in some countries due to its potential for abuse. In the United States, it is marketed as a dietary supplement and known as “gas station heroin”. Of note, given that this is a dietary supplement, the dose of tianeptine in each of the pills may not be standardized.
Tianeptine modulates glutaminergic effects and has full agonist effects at the mu opioid receptor. It enhances serotonin concentrations in the synapse. Despite its structure being similar to tricyclic antidepressants, there have not been reports of sodium channel blocking effects. Deaths have been reported and thought to be related to the respiratory depression that occurs with mu opioid effect.
In 2018, MMWR (MMWR 2018;67:815) reported on tianeptine exposures reported to the National Poison Data System (NPDS) with the South region having the highest percentage of cases. Most exposures were in adults and taken intentionally by ingestion. Our colleagues in Alabama published their experience with 48 cases in 2021 (Clin Tox 2021;59:152-7). Lethargy was the most common presentation. Agitation was also a presentation from its misuse. Myoclonic movements were reported in 2 cases. No cardiac conduction abnormalities were reported.
Physical dependence may occur, and withdrawal is reported after chronic use. Patients may have to take large numbers of pills every 4-6 hours to prevent withdrawal symptoms. There are case reports of using buprenorphine/naloxone for treatment of the withdrawal and dependence. Neonatal abstinence syndrome has been described after a mom was taking tianeptine during the pregnancy.
History of use or misuse will be most helpful in making the diagnosis as confirmation of exposure is challenging. This does not show up on urine drug screens.
Question by Saralyn Williams, MD, Professor of Emergency Medicine, Medicine, and Pediatrics VUMC
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DONNA SEGER, MD
Department of Medicine
Tennessee Poison Center
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