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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] [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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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] [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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Glycyrrhiza Genus: Enlightening Phytochemical Components for Pharmacological and Health-Promoting Abilities. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:7571132. [PMID: 34349875 PMCID: PMC8328722 DOI: 10.1155/2021/7571132] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/12/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023]
Abstract
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.
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Abstract
RATIONALE Excessive ingestion of licorice can cause pseudohyperaldosteronism. A few case reports in the available literature have described significant hypokalemia secondary to licorice consumption with clinical manifestations of muscle weakness, paralysis, or severe hypertension. To our knowledge, no report has discussed severe asymptomatic hypokalemia associated with licorice consumption. PATIENT CONCERNS A 79-year-old man presented to the urology clinic with a several-month history of urinary frequency and a weak stream. Routine laboratory investigations revealed serum potassium (K) level of 1.8 mmol/L, and he was immediately admitted to the nephrology department. DIAGNOSES He was in a good state of health, and systemic and neurological examinations were unremarkable. However, laboratory investigations revealed severe hypokalemia and metabolic alkalosis accompanied with renal K wasting and hypertension, suggesting a state of mineralocorticoid excess. Hormonal studies revealed low serum renin and aldosterone but normal serum cortisol levels. Detailed history taking revealed that he had used licorice tea daily during the preceding 18 months. INTERVENTIONS AND OUTCOME The patient's serum K returned to normal levels after vigorous K replacement and discontinuation of licorice intake. He was also diagnosed with benign prostatic hyperplasia during hospitalization and was treated. LESSONS Chronic licorice ingestion can precipitate severe hypokalemia, although patients may remain asymptomatic. This case report indicates that the severity of a patient's clinical presentation depends on individual susceptibility, as well as the dose and duration of licorice intake.
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Kim HK, Kim SS. Electrical storm induced by hypokalemia associated with herbal medicines containing licorice. Transl Clin Pharmacol 2020; 27:69-72. [PMID: 32055584 PMCID: PMC6989247 DOI: 10.12793/tcp.2019.27.2.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 11/19/2022] Open
Abstract
A 60-year-old woman presented with polymorphic ventricular tachycardia secondary to hypokalemia, which necessitated dozens of DC cardioversions. She was not taking any other medication and denied any vomiting or diarrhea. Further investigation for hypokalemia suggested a hypermineralocorticoid state. Repeated inquiry prompted the patient to admit to taking herbal medicine containing licorice. She was treated with magnesium sulfate, potassium infusion, and intravenous lidocaine. A potassium-sparing diuretic was also prescribed. On the seventh day, the patient was discharged from the hospital with advice to discontinue taking herbal medicines containing licorice. She has been followed up at our outpatient clinic without further symptoms for 3 years. This case highlights the potential for cardiovascular complications associated with consumption of herbal medicines such as licorice. Clinicians should be aware that patients presenting to the emergency department with ventricular arrhythmia and uncertain hypokalemia should be questioned about licorice intake. Obtaining a detailed history from patients admitted to the hospital for electrical storm is essential.
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Affiliation(s)
- Hyun Kuk Kim
- Division of Cardiology of Chosun University Hospital, Gwangju 61453, Korea
| | - Sung Soo Kim
- Division of Cardiology of Chosun University Hospital, Gwangju 61453, Korea
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Adverse Events Associated with Ethical Kampo Formulations: Analysis of the Domestic Adverse-Event Data Reports of the Ministry of Health, Labor, and Welfare in Japan. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:1643804. [PMID: 31118950 PMCID: PMC6500660 DOI: 10.1155/2019/1643804] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/07/2019] [Indexed: 12/13/2022]
Abstract
Objectives Traditional Japanese Kampo medicines have been integrated into the Japanese national health-care system. In Japan, the Ministry of Health, Labor, and Welfare's website discloses adverse drug-event data that have been obtained from medical personnel reports investigated by the Pharmaceutical and Medical Devices Agency. Using these data, we investigated adverse events associated with ethical Kampo formulations. Methods Reports of adverse events associated with ethical Kampo formulations from the domestic adverse-event data were obtained from July 30, 2003, to March 31, 2018. Adverse events were then categorized, and the relationships between categories of adverse events and crude drugs were analyzed. Results There were 4,232 reported adverse events associated with ethical Kampo formulations. The numbers of events by category were as follows: events related to liver injury, 1,193; lung injury, 1,177; pseudoaldosteronism, 889; mesenteric phlebosclerosis, 223; drug eruption, 185; and others, 565. Among events related to both liver injury and lung injury, approximately 70% were suspected to be induced by Kampo formulations containing Scutellariae Radix. The pseudoaldosteronism-related events, which are induced by Glycyrrhizae Radix, included several events related to muscle injury, heart failure, and arrhythmia. Events related to mesenteric phlebosclerosis, believed to be induced by long-term use of Kampo formulas containing Gardeniae Fructus, increased remarkably during the study period. Among the events related to drug eruption, approximately 35% were suspected to be induced by Kampo formulations containing Ephedrae Herba. Conclusion Kampo medicines may cause various adverse events. The present results provide valuable information regarding adverse events associated with Kampo medicines from the viewpoint of patient safety.
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Nazari S, Rameshrad M, Hosseinzadeh H. Toxicological Effects of Glycyrrhiza glabra (Licorice): A Review. Phytother Res 2017; 31:1635-1650. [PMID: 28833680 DOI: 10.1002/ptr.5893] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Somayeh Nazari
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Rameshrad
- Pharmaceutical Research Center, Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Hosseinzadeh
- Pharmaceutical Research Center, Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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McCauley M, Vallabhajosyula S, Darbar D. Proarrhythmic and Torsadogenic Effects of Potassium Channel Blockers in Patients. Card Electrophysiol Clin 2016; 8:481-93. [PMID: 27261836 DOI: 10.1016/j.ccep.2016.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The most common arrhythmia requiring drug treatment is atrial fibrillation (AF), which affects 2 to 5 million Americans and continues to be a major cause of morbidity and increased mortality. Despite recent advances in catheter-based and surgical therapies, antiarrhythmic drugs continue to be the mainstay of therapy for most patients with symptomatic AF. However, many antiarrhythmics block the rapid component of the cardiac delayed rectifier potassium current (IKr) as a major mechanism of action, and marked QT prolongation and pause-dependent polymorphic ventricular tachycardia (torsades de pointes) are major class toxicities.
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Affiliation(s)
- Mark McCauley
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, 840 South Wood Street, Suite 920 (MC715), Chicago, IL 60612, USA
| | - Sharath Vallabhajosyula
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, 840 South Wood Street, Suite 920 (MC715), Chicago, IL 60612, USA
| | - Dawood Darbar
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, 840 South Wood Street, Suite 920 (MC715), Chicago, IL 60612, USA.
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