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Ceccuzzi G, Rapino A, Perna B, Costanzini A, Farinelli A, Fiorica I, Marziani B, Cianci A, Rossin F, Cesaro AE, Spampinato MD, De Giorgio R, Guarino M. Liquorice Toxicity: A Comprehensive Narrative Review. Nutrients 2023; 15:3866. [PMID: 37764649 PMCID: PMC10537237 DOI: 10.3390/nu15183866] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/26/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Renowned since ancient times for its medical properties, liquorice is nowadays mainly used for flavoring candies or soft drinks. Continuous intake of large amounts of liquorice is a widely known cause of pseudo-hyperaldosteronism leading to hypertension and hypokalemia. These manifestations are usually mild, although in some cases may generate life-threatening complications, i.e., arrhythmias, muscle paralysis, rhabdomyolysis, and coma. In addition, liquorice has an important estrogenic-like activity. METHODS We summarized the current knowledge about liquorice and reviewed 104 case reports in both the English and Italian languages from inception to June 2023 concerning complications due to an excess of liquorice intake. RESULTS In contrast to most published data, female sex and old age do not appear to be risk factors. However, hypertension and electrolyte imbalance (mainly hypokalemia) are prevalent features. The detection of glycyrrhetinic acid in blood is very uncommon, and the diagnosis is essentially based on an accurate history taking. CONCLUSIONS Although there is not a significant mortality rate, liquorice toxicity often requires hospitalization and therefore represents a significant health concern. Major pharmaceutical drug regulatory authorities should solicit public awareness about the potentially dangerous effects caused by excessive use of liquorice.
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Affiliation(s)
- Giovanna Ceccuzzi
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Alessandro Rapino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Benedetta Perna
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Anna Costanzini
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Andrea Farinelli
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Ilaria Fiorica
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Beatrice Marziani
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Antonella Cianci
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Federica Rossin
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Alice Eleonora Cesaro
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Michele Domenico Spampinato
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
- Department of Emergency, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Matteo Guarino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
- Department of Emergency, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy
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Fan ZJ, Liu JM, Li XX, Cui J, Guo B, Lin Q, Zhuang R, Wu ZB, Wu Y. Glycyrrhizin-Induced Pseudohyperaldosteronism: A Case Report. Chin J Integr Med 2022; 28:644-649. [PMID: 35015223 DOI: 10.1007/s11655-021-3312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/03/2022]
Abstract
In conclusion, this case should remind clinicians of the potential dangers of glycyrrhizin (high blood pressure, low blood potassium and abnormal changes in ECG, among other effects). The timely detection and effective treatment of glycyrrhizin-induced PsHA can prevent the occurrence of serious complications. The importance of taking a detailed medical history is also emphasized.
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Affiliation(s)
- Zong-Jing Fan
- Department of Cardiology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Jin-Min Liu
- Department of Cardiology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Xing-Xing Li
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Jie Cui
- Department of Cardiology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Bin Guo
- Department of Cardiology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Quan Lin
- Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Rui Zhuang
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Zheng-Bo Wu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yang Wu
- Department of Cardiology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China.
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Husain I, Bala K, Khan IA, Khan SI. A review on phytochemicals, pharmacological activities, drug interactions, and associated toxicities of licorice (
Glycyrrhiza
sp.). Food Frontiers 2021. [DOI: 10.1002/fft2.110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Islam Husain
- National Center for Natural Products Research, School of Pharmacy University of Mississippi, University, MS 38677 USA
| | - Kiran Bala
- Department of P.G. Studies and Research in Biological Science Rani Durgavati University Jabalpur India
| | - Ikhlas A. Khan
- National Center for Natural Products Research, School of Pharmacy University of Mississippi, University, MS 38677 USA
- Department of BioMolecular Sciences, School of Pharmacy University of Mississippi, University, MS 38677 USA
| | - Shabana I. Khan
- National Center for Natural Products Research, School of Pharmacy University of Mississippi, University, MS 38677 USA
- Department of BioMolecular Sciences, School of Pharmacy University of Mississippi, University, MS 38677 USA
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Jafari F, Jafari M, Moghadam AT, Emami SA, Jamialahmadi T, Mohammadpour AH, Sahebkar A. A Review of Glycyrrhiza glabra (Licorice) Effects on Metabolic Syndrome. Natural Products and Human Diseases 2021; 1328:385-400. [DOI: 10.1007/978-3-030-73234-9_25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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.
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Affiliation(s)
| | - Pinak Shah
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
| | - Leo Yamaguchi
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
| | - Vanessa Josef
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
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Abstract
PURPOSE OF REVIEW To review latest reports of the food products which might increase blood pressure and therefore might participate in the pathogenesis of hypertension. RECENT FINDINGS Results of clinical study suggest that consumption of high-sodium food leads to transient increase in plasma sodium concentration. This is accompanied by blood pressure increase. Results of both clinical and experimental studies suggest direct vasculotoxic effects of sodium. Increased plasma sodium concentration could mediate its effects on blood pressure by changes in endothelial cell stiffness and glycocalyx integrity. Energy drinks are non-alcoholic beverages with increasing popularity. Clinical, interventional, randomized, placebo controlled, and cross-sectional studies showed that energy drinks may increase arterial blood pressure. Blood pressure increase after exposure for the energy drinks is mainly related to the caffeine content in these drinks. Many case reports were published concerning the clinically significant increase in blood pressure caused by the consumption of liquorice root or food products containing liquorice, such as candies, tea, Pontefract cookies, and chewing gum. Liquorice contains a precursor of glycyrrhetic acid. Glycyrrhetic acid reduces the activity of the 11β-hydroxysteroid dehydrogenase type 2 (11ß-HSD2) isoenzyme, which leads to activation of the mineralocorticoid receptor by cortisol in the distal convoluted tubule resulting in hypertension, hypokalemia, and metabolic alkalosis. The relationship between chronic alcohol intake and blood pressure is well established on the basis of a diverse body of evidence including animal experiments, epidemiological studies, mendelian randomization studies, and interventional studies. Results of recent studies suggested that binge drinking (i.e., episodic consumption of a very high amount of alcohol beverages) has pronounced hypertensinogenic effects. Recently, it was documented that also low doses of alcohol may increase the risk of cardiovascular complications. Therefore, the amount of alcohol consumption that is safe is zero. High-salt food products, energy drinks, food products containing liquorice, and alcoholic beverages have hypertensinogenic properties. Patients with hypertension and other cardiovascular diseases should avoid even accidental consumption of these food products.
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Deutch MR, Grimm D, Wehland M, Infanger M, Krüger M. Bioactive Candy: Effects of Licorice on the Cardiovascular System. Foods 2019; 8:E495. [PMID: 31615045 DOI: 10.3390/foods8100495] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Jean-Pierre Falet
- Departments of Neurology (Falet) and Internal Medicine (Elkrief, Green), McGill University, Montréal, Que.
| | - Arielle Elkrief
- Departments of Neurology (Falet) and Internal Medicine (Elkrief, Green), McGill University, Montréal, Que
| | - Laurence Green
- Departments of Neurology (Falet) and Internal Medicine (Elkrief, Green), McGill University, Montréal, Que
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Foster S, Foster R, Jackson P, Song S. All sorts of tests, only one question: an unexpected cause of hypertension. BMJ Case Rep 2017; 2017:bcr-2017-222077. [PMID: 29127128 DOI: 10.1136/bcr-2017-222077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 48-year-old woman presented to the Accident and Emergency department with a 4 month history of headaches, nausea and dizziness. She was found to have severe hypertension and hypokalaemia. Extensive investigations did not find any secondary cause for hypertension. The patient was discharged with oral doxazosin therapy which controlled the blood pressure. Before the follow-up appointment at the hypertension clinic, the patient and her husband identified that her headaches coincided with liquorice tea consumption of up to three cups per day. This information was not obtained in the clinical assessment. The patient is now headache and medication free after cessation of liquorice tea. Liquorice ingestion is often a forgotten reversible cause of hypertension. A good history is key to this diagnosis.
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Affiliation(s)
- Sarah Foster
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel Foster
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Peter Jackson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Soon Song
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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