Lesson of the week: hypokalaemia and hypertension associated with use of liquorice flavoured chewing gum

Klerk, G. J. de; Nieuwenhuis, M. G.; Beutler, Jaap J.

doi:10.1136/bmj.314.7082.731

Cited by 94 publications

(45 citation statements)

References 9 publications

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“…As cortisol has the same affinity to the aldosterone receptors as aldosterone this gives the cortisol the effect of mineralocorticoid, leading to pseudohyperaldosteronism with fluid and sodium retention as well as serum potassium reduction. [6][7][8][9][10][11]13 Liquorice can also lead to a suppressed renin concentration, either secondary to the hypervolaemia or by direct inhibition of the renin production. 7,11,[14][15][16] The diagnosis of liquorice-induced hypertension should thus be suspected if the renin concentration in plasma or plasma-renin activity is suppressed, depending on the method used by the respective laboratory.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4][5] Even apparently marginal doses of liquorice as in liquorice-flavoured chewing gum, chewing tobacco and Pontefract cakes have proved to cause hypokalaemia and hypertension. 2,6,7 The aim of the present study was to investigate the dose-response relationship, the time-response relationship and the inter-individual response variability to glycyrrhetinic acid. …”

Section: Introductionmentioning

confidence: 99%

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Liquorice-induced rise in blood pressure: a linear dose-response relationship

et al. 2001

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To clarify the dose-response and the time-response relationship between liquorice consumption and rise in blood pressure and explore the inter-individual variance this intervention study was designed and executed in research laboratories at University hospitals in Iceland and Sweden. Healthy, Caucasian volunteers who also served as a control for himself/herself consumed liquorice in various doses, 50-200 g/day, for 2-4 weeks, corresponding to a daily intake of 75-540 mg glycyrrhetinic acid, the active substance in liquorice. Blood pressure was measured before, during and after liquorice consumption. Systolic blood pressure increased by 3.1-14.4 mm Hg (P Ͻ 0.05 for all), demonstrating a dose-

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Liquorice-induced rise in blood pressure: a linear dose-response relationship

et al. 2001

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“…11-B-hydroxysteroid dehydrogenase activity shows variations among individuals, possibly due to genetic differences. Therefore, the severity and onset of symptoms attributable to licorice ingestion are related to the individual susceptibility as well as the duration of use and the dose (12). Although there are reports on symptomatic pseudohyperaldosteronism with small amounts of glycyrrhizic acid in a chewing gum (13), there are also reports with ingestion of quite large amounts.…”

Section: Türk Nefroloji Diyaliz Ve Transplantasyon Dergisi Turkish Nementioning

confidence: 91%

Licorice Ingestion; An Unusual Cause of Rhabdomyolysis and

Danış¹,

Ruhı²,

Berketoglu³

et al. 2015

Turk Neph Dial Transpl

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Licorice root has glycyrrhizic acid as the active ingredient and is responsible for a primary hyperaldosteronism-like syndrome with hypokalemia, metabolic alkalosis, and hypertension, typically accompanying low aldosterone. Herein, we present a rare complication of licorice consumption with acute renal failure.A 49-year-old male patient was admitted to emergency department with generalized muscle pain/ weakness, nausea, and dark urine. He was suffering from confusion and somnolence and the general condition was moderate. At laboratory assessment, potassium was 2.3 mEq/L, sodium 141 mEq/L, urea 146 mg/dl , creatinine 6.24 mg/dl, and total creatine kinase 4597 U/L. He had metabolic alkalosis (pH 7.59, HCO 3-37.2 mmol/L). Hemodialysis was performed because of uremic neurological symptoms. His detailed anamnesis revealed consumption of herbal medication for the last 1.5 years to treat gastric complaints. The herbal medication included 16 gr licorice root powder (~600-750 mg glycyrrhizic acid) per 100 gr. The plasma aldosterone concentration was significantly suppressed [1.6 pg/ml (normal; 38.1-300 pg/mL)]. Under these conditions, our final diagnosis was hypokalemic rhabdomyolysis and acute renal failure due to licorice ingestion. We present a rare life-threating effect of licorice ingestion in this report. Furthermore, we want to draw attention to the importance of a detailed medical history, including the use of herbal medications and regional traditional characteristics to confirm the diagnosis.Key wORdS: Licorice, Rhabdomyolysis, Acute renal failure Öz Meyan kökü; Güneydoğu Anadolu'da geleneksel bir içecek olmasının yanı sıra gıda/bitkisel ilaç endüstrisinde kullanılır. Aktif maddesi gliserizik asittir, primer hiperaldestronizim benzeri tablo ile hipokalemi, metabolik alkaloz ve hipertansiyona neden olabilir. Bu olgu sunumunda meyan köküne bağlı gelişen, literatürde nadir olan, bir rabdomiyoliz ve akut böbrek yetmezliği olgusu sunulmuştur. 49 yaşında erkek; kas güçsüzlüğü/ağrısı, bulantı, idrarda koyulaşma yakınmaları ile acil servise başvurdu. Fizik muayenesinde bilinç bulanıklığı ve uykuya meyil vardı. Hastanın laboratuvar bulguları; potasyum 2,3 mEq/L, sodyum141 mEq/L, üre 146 mg/dl, kreatin 6,24 mg/dl, total kreatin kinaz 4597 U/L idi, ayrıca metabolik alkalozu (pH 7,59, HCO 3-37.2 mmol/L) mevcuttu. Hasta üremik nörolojik bulguları nedeniyle hemodiyalize alındı. Bilinç durumu düzelince alınan detaylı anamnezde yaklaşık 1,5 yıldır mide yakınması nedeniyle bitkisel ilaçlar kullandığı ve bitkisel ilacın 100 gr'nın 16 gr meyan kökü (~600-750 mg gliserizik asit) içerdiği öğrenildi. Bu bulgular ışığında kesin tanımız; meyan kökü alımına bağlı hipokalemi, rabdomiyoliz ve akut böbrek yetmezliği oldu. Hastanın plazma aldosteron düzeylerindeki baskılanma da tanımızı destekler nitelikteydi [1,6 pg/ml (normal; 38,1-300 pg/ml)].Bitkisel ilaçlar ve gıda endüstrisinde yaygın olarak kullanılan meyan kökü yaşamı tehdit edici düzeyde akut böbrek yetmezliğine neden olabilir. Ayrıca bu olgu doğrultusunda hekimlere, bitki...

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“…It was evident that most of the published complications are linked to the aldosterone-like action of licorice. The two main categories of complications were licoriceinduced hypertension [Mumoli and Cei, 2008;Scali et al 1990;Holmes et al 1970;De Klerk et al 1997] and hypokalemic myopathy [Yaguchi et al 2008;Maresca et al 1988;Caradonna et al 1992;Lin et al 2003a;Lin et al 2003b;Gross et al 1966;Tancevski et al 2008]. In reports of licorice-induced hypertension, prognosis was favorable with good response after cessation of licorice and starting antihypertensive medications.…”

Section: Licorice-related Complicationsmentioning

confidence: 99%

Licorice abuse: time to send a warning message

Omar

Komarova

Elghonemi

et al. 2012

Therapeutic Advances in Endocrinology

184

160

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Licorice extract has always been recognized as a sweetener and a thirst quencher. Its nutritive value is overrated by many who consume significant amounts and are prone to complications. Glycyrrhetic acid, the active metabolite in licorice, inhibits the enzyme 11-ß-hydroxysteroid dehydrogenase enzyme type 2 with a resultant cortisol-induced mineralocorticoid effect and the tendency towards the elevation of sodium and reduction of potassium levels. This aldosterone-like action is the fundamental basis for understanding its health benefits and the wide spectrum of adverse effects. Herein, we present a comprehensive review of licorice along with the reported complications related to excess intake. Despite its apparent use in a few clinical scenarios, the daily consumption of licorice is never justified because its benefits are minor compared to the adverse outcomes of chronic consumption. The review highlights the importance of investigating the dietary habits and herbal remedies which are being used worldwide on cultural and habitual bases rather than reliable scientific evidence. Licorice is a US Food and Drug Administration (FDA) approved food supplement used in many products without precise regulations to prevent toxicity. Increased awareness among the public is required through TV commercials, newspapers, internet sites, magazines and product labels regarding the upper limit of ingestion and health hazards associated with excess intake. We hope that this review will serve as a warning message that should be transmitted from physicians to patients to avoid excessive licorice intake as well as a message to the FDA to start regulating the use of this substance.

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Lesson of the week: hypokalaemia and hypertension associated with use of liquorice flavoured chewing gum

Cited by 94 publications

References 9 publications

Liquorice-induced rise in blood pressure: a linear dose-response relationship

Liquorice-induced rise in blood pressure: a linear dose-response relationship

Licorice Ingestion; An Unusual Cause of Rhabdomyolysis and

Licorice abuse: time to send a warning message

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