Congestive heart failure caused by digitalis toxicity in an elderly man taking a licorice-containing chinese herbal laxative

Glycyrrhiza Genus: Enlightening Phytochemical Components for Pharmacological and Health-Promoting Abilities

The Glycyrrhiza genus, generally well-known as licorice, is broadly used for food and medicinal purposes around the globe. The genus encompasses a rich pool of bioactive molecules including triterpene saponins (e.g., glycyrrhizin) and flavonoids (e.g., liquiritigenin, liquiritin). This genus is being increasingly exploited for its biological effects such as antioxidant, antibacterial, antifungal, anti-inflammatory, antiproliferative, and cytotoxic activities. The species Glycyrrhiza glabra L. and the compound glycyrrhizin (glycyrrhizic acid) have been studied immensely for their effect on humans. The efficacy of the compound has been reported to be significantly higher on viral hepatitis and immune deficiency syndrome. This review provides up-to-date data on the most widely investigated Glycyrrhiza species for food and medicinal purposes, with special emphasis on secondary metabolites' composition and bioactive effects.

Adverse drug event of hypokalaemia-induced cardiotoxicity secondary to the use of laxatives: A systematic review of case reports

WHAT IS KNOWN AND OBJECTIVE

The imbalance in serum potassium caused by laxatives can negatively affect the cardiovascular system, leading to life-threatening consequences. Our objective was to evaluate the reported evidence of adverse events related to the cardiac system due to laxative-induced hypokalaemia from case reports.

METHODS

A systematic electronic literature search of PubMed, Embase, the Cochrane Library and Science Direct was conducted for the period 1995-2019. In these databases, search terms describing hypokalaemia and cardiotoxicity were combined with the term laxative use.

RESULTS AND DISCUSSION

Over the 23 years, 27 incidents were identified in 12 countries. There were 19 female and eight male patients, with ages ranging from 1 month to 93 years. The frequency of reported cases according to severity was the following: severe hypokalaemia 48%, moderate hypokalaemia 44.4% and mild hypokalaemia 7.4%. In 70% of patients, the effect of laxative on the heart was typical hypokalaemic electrographic changes, 7.4% showed abnormal changes in cardiac rhythm, whereas in 18.5%, the cardiotoxicity observed was a very serious kind. Two patients died due to severe cardiac effects.

WHAT IS NEW AND CONCLUSION

The laxatives-along with the involvement of some other contributing factors-caused mild-to-severe hypokalaemic cardiotoxicity. These factors were non-adherence of the patient to the recommended dosage, laxative abuse, drug-drug and drug-disease interactions, non-potassium electrolyte imbalances and the use of herbal laxatives. We recommend that laxatives and aggravating factors should be taken into account in the assessment of patients with suspected hypokalaemic cardiotoxicity.

Effect of licorice on patients with HSD11B1 gene polymorphisms- a pilot study

The positive association of HSD11B1 gene polymorphism with type 2 diabetes (T2D) and prediabetic conditions has been revealed. In the current study, we assessed the effectiveness of licorice on the clinical profile of the patients with HSD11B1 gene polymorphism. Licorice (Glycyrrhiza Glabra) is a competitive inhibitor of 11 beta-hydroxysteroid dehydrogenase 1 (11β-HSD1) enzyme and has been traditionally reported as an anti-ulcer, anti-pyretic, anti-thirst, anti-inflammatory, hypoglycemic and hypolipidemic agent. The aim of the study was to assess the effectiveness of licorice on the clinical profile of participants with HSD11B1 gene polymorphism. The study was performed using diabetic patients with HSD11B1 gene polymorphism. Biochemical and anthropometric parameters were measured using standard diagnostic tools. Fourteen patients were divided into two groups by simple randomization, Licorice group (treated with 750 mg licorice/day for three weeks), and placebo group (treated with 750 mg placebo/day for three weeks). Investigations were repeated at the end of three weeks. Licorice showed a significant reduction in serum insulin levels (p = 0.03). There was no significant change in any other clinical parameters either by licorice or placebo. Conclusively, licorice moderately improves serum insulin levels in patients with HSD11B1 gene polymorphism. From our pilot study, the safety of licorice is confirmed at a dose of 750 mg/day. However, the study can be repeated at a higher dose to show its effectiveness and safety.

Bioactive Candy: Effects of Licorice on the Cardiovascular System

Licorice, today chiefly utilized as a flavoring additive in tea, tobacco and candy, is one of the oldest used herbs for medicinal purposes and consists of up to 300 active compounds. The main active constituent of licorice is the prodrug glycyrrhizin, which is successively converted to 3β-monoglucuronyl-18β-glycyrrhetinic acid (3MGA) and 18β-glycyrrhetinic acid (GA) in the intestines. Despite many reported health benefits, 3MGA and GA inhibit the 11-β-hydrogenase type II enzyme (11β-HSD2) oxidizing cortisol to cortisone. Through activation of mineralocorticoid receptors, high cortisol levels induce a mild form of apparent mineralocorticoid excess in the kidney and increase systemic vascular resistance. Continuous inhibition of 11β-HSD2 related to excess licorice consumption will create a state of hypernatremia, hypokalemia and increased fluid volume, which can cause serious life-threatening complications especially in patients already suffering from cardiovascular diseases. Two recent meta-analyses of 18 and 26 studies investigating the correlation between licorice intake and blood pressure revealed statistically significant increases both in systolic (5.45 mmHg) and in diastolic blood pressure (3.19/1.74 mmHg). This review summarizes and evaluates current literature about the acute and chronic effects of licorice ingestion on the cardiovascular system with special focus on blood pressure. Starting from the molecular actions of licorice (metabolites) inside the cells, it describes how licorice intake is affecting the human body and shows the boundaries between the health benefits of licorice and possible harmful effects.

Toxicological Effects of Glycyrrhiza glabra (Licorice): A Review

Licorice (Glycyrrhiza glabra) has been considered as an herbal drug since ancient time. Nowadays, it is a well-known spice that possesses worth pharmacological effects. However, some relevant articles have revealed negative impacts of licorice in health. By considering the great wishes in using herbal medicine, it is important to show adverse effects of herbal medicine in health. At present, there are misunderstandings toward the safety of herbal medicines. Herein, we gathered scientific research projects on the toxicity effects of licorice and glycyrrhizin to highlight their safety. In this regards, we categorized our findings about the toxicity effects of licorice and glycyrrhizin in acute, sub-acute, sub-chronic, and chronic states. Besides, we discussed on the cytotoxicity, genotoxicity, mutagenicity, and carcinogenicity of licorice and glycyrrhizin as well as their developmental toxicity. This review disclosed that G. glabra and glycyrrhizin salts are moderately toxic. They need to be used with caution during pregnancy. G. glabra and glycyrrhizin possess selective cytotoxic effects on cancerous cells. The most important side effects of licorice and glycyrrhizin are hypertension and hypokalemic-induced secondary disorders. Licorice side effects are increased by hypokalemia, prolonged gastrointestinal transient time, decreased type 2 11-beta-hydroxysteroid dehydrogenase activities, hypertension, anorexia nervosa, old age, and female sex. Copyright © 2017 John Wiley & Sons, Ltd.

Glycyrrhiza glabra

Liquorice foliage

Reducing drug-herb interaction risk with a computerized reminder system

Background

Traditional Chinese medicine (TCM) and Western medicine are both popular in Taiwan. Approximately 14.1% of Taiwanese residents use Western drugs and Chinese herbs concurrently; therefore, drug–herb interaction is critical to patient safety. This paper presents a new procedure for reducing the risk of drug interactions.

Methods

Hospital computer systems are modified to ensure that drug–herb interactions are automatically detected when a TCM practitioner is writing a prescription. A pop-up reminder appears, warning of interactions, and the practitioner may adjust doses, delete herbs, or leave the prescription unchanged. A pharmacist will receive interaction information through the system and provide health education to the patient.

Results

During the 2011–2013 study period, 256 patients received 891 herbal prescriptions with potential drug–herb interactions. Three of the 50 patients who concurrently used ginseng and antidiabetic drugs manifested hypoglycemia (fasting blood sugar level ≤70 mg/dL).

Conclusion

Drug–herb interactions can cause adverse reactions. A computerized reminder system can enable TCM practitioners to reduce the risk of drug–herb interactions. In addition, health education for patients is crucial in avoiding adverse reaction by the interactions.

Licorice abuse: time to send a warning message

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.

Complications of traditional Chinese/herbal medicines (TCM)--a guide for perplexed oncologists and other cancer caregivers

INTRODUCTION

Cancer patients often seek complementary or alternative medicines to supplement or replace treatments prescribed by licensed medical practitioners. Traditional Chinese/herbal medicine (TCM) is a popular complementary intervention among cancer patients of Asian ethnicity, many of whom take it during their conventional treatment. Few of these patients inform their doctors, however, creating a risk of unexpected sequelae arising from either pharmacologic toxicity, unsuitable dosing, interactions with anti-cancer drugs or other medications, adulteration, or idiosyncratic reactions. If unrecognized, these problems may be misattributed to conventional treatment toxicity or disease progression, and remedial action may be inappropriate or delayed.

GOALS OF WORK

The purpose of this review is to help oncologists recognize the common presentations of TCM-related problems in cancer patients-such as abnormal liver function tests, unexpectedly severe myelosuppression, hemostatic defects, renal functional impairment, or suspected drug interactions-and to teach strategies by which these problems can be anticipated, prevented, or managed.

CONCLUSION

Through sensitive understanding of the reasons favoring TCM usage, oncologists can gain the trust and respect of their TCM-using patients while ensuring the safety and efficacy of conventional anticancer treatments.

Consumption of herbal remedies and dietary supplements amongst patients hospitalized in medical wards

AIMS

Herbal remedies may have adverse effects and potentially serious interactions with some commonly prescribed conventional medications. Little is known about consumption of herbal remedies and dietary supplements by hospitalized patients. The aim was to evaluate the rate of consumption and characterize the patients hospitalized in internal medicine departments who consume herbal remedies and dietary supplements. Also, to assess the medical teams' awareness and assess the percentage of patients with possible drug-herb interactions.

METHODS

Patients hospitalized in the medical wards of two hospitals in Israel were interviewed about their use of herbal remedies or dietary supplements. The medical records were searched for evidence that the medical team had knowledge of the use of herbal remedies or dietary supplements.

RESULTS

Two hundred and ninety-nine hospitalized medical patients were interviewed. Of the participants, 26.8% were herbal or dietary supplement consumers (HC). On multivariate analysis the only variates associated with herbal or dietary supplement consumption were the hospital [odds ratio (OR) 2.97, 95% confidence interval (CI) 1.29, 6.52], income (OR 0.39, 95% CI 0.15, 1.05), smoking habits (OR 0.17, 95% CI 0.05, 0.55) and benign prostatic hypertrophy (OR 4.64, 95% CI 1.3, 16.5). Ninety-four percent of the patients had not been asked specifically of herbal consumption by the medical team. Only 23% of the hospital's medical files of the HC patients had any record of the use of herbal or dietary supplements. Seven possible drug-herbal interactions were encountered (7.1%). The most serious was an interaction between camomile tea and ciclosporin.

CONCLUSIONS

Herbal remedy consumption is common amongst patients hospitalized in internal medicine wards and is often overlooked by the medical team. Patients and doctors should be more aware of the possible adverse effects and of the potential of herb-drug interactions.

The potential impact of the use of homeopathic and herbal remedies on monitoring the safety of prescription products

The purpose of this paper is to explore the possibility that adverse reactions and drug interactions arising from the use of homeopathic and herbal medicines could lead to confusion when adverse reactions to conventional medicines are reported. An extensive literature review was conducted on the occurrence of adverse reactions and drug interactions following the use of homeopathic or herbal remedies, and the potential for these to confound adverse event reporting to conventional medicines considered. The survey demonstrates the potential for herbal remedies and homeopathic products, to produce adverse drug reactions or drug interactions, and shows the scope for potential for confusion with those arising from conventional medicines. There is a need for greater awareness that adverse reactions apparently due to a conventional medicine, might in reality be due to a herbal medicine or a drug interaction between a herbal medicine and a conventional drug, particularly when a health professional is unaware of the extent of a patient's self-medication with alternative therapies.