Trick or Treat? Licorice-Induced Hypokalemia: A Case Report

Abstract

The by-products of black licorice metabolism are toxic in high concentrations. Patients who consume large quantities of black licorice are at risk of developing an acquired syndrome of apparent mineralocorticoid excess. This presents clinically as hypertension, hypernatremia, and hypokalemia. Here, we present the unique case of a 74-year-old woman with a past medical history of neurogenic orthostatic hypotension, on fludrocortisone, who presented to the emergency department with asymptomatic hypokalemia (2.4 mmol/L) as detected in outpatient laboratory studies. During her hospital stay, it was discovered that the patient was consuming excessive amounts of black licorice. With this information, the synergistic interaction of fludrocortisone and black licorice was recognized as the cause of the patient's severe hypokalemia. The patient's fludrocortisone was stopped and she was treated with multiple courses of potassium repletion. Upon discharge, her fludrocortisone was discontinued, and she was prescribed midodrine to treat her neurogenic orthostatic hypertension. While small amounts of black licorice are safe, excessive licorice consumption can cause severe disease. Our case presents an opportunity to appreciate the plethora of etiologies for severe hypokalemia and the importance of taking a thorough patient history to avoid potentially fatal clinical outcomes.

A Licorice-Flavored Edema: A Case Report of Glycyrrhizic Acid Toxicity From Chronic Licorice Root Consumption

“…Licorice-induced AME is reversible, taking into account that the inhibitory action on 11-β-HSD type 2 lasts about two weeks. In addition, the renin-angiotensin-aldosterone system may take up to six months to recover to its previous level, which may be temporarily supplemented with potassium-saving diuretics, spironolactone, and dexamethasone, keeping in mind that glucocorticoids may be too strong and have more side effects [ 3 , 9 ].…”

Safety Review of Herbs and Supplements in Heart Disease, Diabetes, and COVID-19

“…Cases of hypokalemia and hypertension have been reported after daily ingestion of licorice tea or after short-term high dose [52][53][54]. In one case patient was combining licorice with the glucocorticoid medication fludrocortisone [55]. The active components of licorice, glycyrrhizinates, inhibit the enzyme responsible for inactivating cortisol and bind to mineralocorticoid receptors resulting in reversible hyper-mineralocorticoid effects [56].…”

Glycyrrhizinic acid in licorice products on the Danish market

“…In any case, studies have clearly demonstrated adverse health effects after excessive licorice consumption (Deutch, Grimm, Wehland, Infanger, & Krüger, 2019), thus consumption as food should be limited to safe intake levels. Symptoms including hypertension, hypokalemia, and edema are well documented in review articles (Isbrucker & Burdock, 2006;Luís, Domingues, & Pereira, 2018;Nazari, Rameshrad, & Hosseinzadeh, 2017;Omar et al, 2012) as well as case reports including cardiac arrest (Albermann, Musshoff, Hagemeier, & Madea, 2010;Allcock & Cowdery, 2015;Benge, Shah, Yamaguchi, & Josef, 2020;Celik et al, 2012;Chehri, Holmager, Stender, & Friis-Hansen, 2021;Edelman, Butala, Avery, Lundquist, & Dighe, 2020;Kwon, Oh, & Choi, 2020;McHugh, Nagabathula, & Kyithar, 2021;Murphy, Agger, & Rainey, 2009;Støving et al, 2011;Varma & Ross, 2017). In Europe, these health concerns were addressed officially by the Scientific Committee on Food (SCF) who expressed the opinion that "regular ingestion should not exceed 100 mg glycyrrhizin per day from all sources, this figure is regarded as provisional until more extensive data becomes available" (SCF, 1992).…”