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Plant Poisoning, Licorice: Follow-up

Author: Seth Schonwald, MD, FACEP, FACMT, Consulting Staff, Director of Toxicology, Department of Urgent Care, East Boston Neighborhood Health Center
Contributor Information and Disclosures

Updated: Jul 6, 2009

Follow-up

Further Inpatient Care

  • Consider admitting patients with the following:
    • Severe electrolyte abnormalities
    • Symptomatic hypokalemia
    • Severe or symptomatic hypertension
    • Progressive weakness or paralysis
    • Rhabdomyolysis
    • Pulmonary edema

Further Outpatient Care

  • Frequent assessment of hypertension and hypokalemia, as well as the need for further potassium supplements and diuretics, may be included in outpatient care.

Inpatient & Outpatient Medications

  • Potassium chloride (Use glucose-free solutions during intravenous administration to avoid worsening hypokalemia.)
  • Potassium-sparing diuretics (eg, triamterene, spironolactone

Prognosis

  • Patients generally fully recover with discontinued exposure.
    • After licorice exposure is discontinued, spontaneous correction of hypertension and hypokalemia generally occur within several weeks; however, months may pass before the renin-aldosterone system becomes active again.22
    • Muscle weakness/paralysis may resolve within days of potassium replacement.

Patient Education

  • Educate patients on the avoidance of natural licorice and GZA-containing products.

Miscellaneous

Medicolegal Pitfalls

  • Failure to query regarding ingestion of natural licorice and use of herbal medicines, snuffs, and chewing tobaccos to ensure cessation of further exposure
  • Failure to anticipate respiratory complications
  • Failure to anticipate electrolyte-induced dysrhythmias
  • Failure to ensure close outpatient follow-up
 


More on Plant Poisoning, Licorice

Overview: Plant Poisoning, Licorice
Differential Diagnoses & Workup: Plant Poisoning, Licorice
Treatment & Medication: Plant Poisoning, Licorice
Follow-up: Plant Poisoning, Licorice
References
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References

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  2. Carmines EL, Lemus R, Gaworski CL. Toxicologic evaluation of licorice extract as a cigarette ingredient. Food Chem Toxicol. Sep 2005;43(9):1303-22. [Medline].

  3. Davis EA, Morris DJ. Medicinal uses of licorice through the millennia: the good and plenty of it. Mol Cell Endocrinol. Jun 1991;78(1-2):1-6. [Medline].

  4. Anderson DM, Smith WG. The antitussive activity of glycyrrhetinic acid and its derivatives. J Pharm Pharmacol. Jul 1961;13:396-404. [Medline].

  5. Krausse R, Bielenberg J, Blaschek W, Ullmann U. In vitro anti-Helicobacter pylori activity of Extractum liquiritiae, glycyrrhizin and its metabolites. J Antimicrob Chemother. Jul 2004;54(1):243-6. [Medline].

  6. Cooper H, Bhattacharya B, Verma V, McCulloch AJ, Smellie WS, Heald AH. Liquorice and soy sauce, a life-saving concoction in a patient with Addison's disease. Ann Clin Biochem. Jul 2007;44(Pt 4):397-9. [Medline].

  7. Ross EJ. Liquorice and Addison's disease. Br Med J. Jun 20 1970;2(5711):733. [Medline].

  8. Dhiman RK, Chawla YK. Herbal medicines for liver diseases. Dig Dis Sci. Oct 2005;50(10):1807-12. [Medline].

  9. Kim YW, Kang HE, Lee MG, Hwang SJ, Kim SC, Lee CH, et al. Liquiritigenin, a flavonoid aglycone from licorice, has a choleretic effect and the ability to induce hepatic transporters and phase-II enzymes. Am J Physiol Gastrointest Liver Physiol. Feb 2009;296(2):G372-81. [Medline].

  10. Farese RV Jr, Biglieri EG, Shackleton CH, Irony I, Gomez-Fontes R. Licorice-induced hypermineralocorticoidism. N Engl J Med. Oct 24 1991;325(17):1223-7. [Medline].

  11. Walker BR, Edwards CR. Licorice-induced hypertension and syndromes of apparent mineralocorticoid excess. Endocrinol Metab Clin North Am. Jun 1994;23(2):359-77. [Medline].

  12. van Uum SH. Liquorice and hypertension. Neth J Med. Apr 2005;63(4):119-20. [Medline].

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  14. Khanna A, Kurtzman NA. Metabolic alkalosis. J Nephrol. Mar-Apr 2006;19 Suppl 9:S86-96. [Medline].

  15. Armanini D, Bonanni G, Palermo M. Reduction of serum testosterone in men by licorice. N Engl J Med. Oct 7 1999;341(15):1158. [Medline].

  16. Armanini D, Mattarello MJ, Fiore C, Bonanni G, Scaroni C, Sartorato P. Licorice reduces serum testosterone in healthy women. Steroids. Oct-Nov 2004;69(11-12):763-6. [Medline].

  17. Biglieri EG. Spectrum of mineralocorticoid hypertension. Hypertension. Feb 1991;17(2):251-61. [Medline].

  18. Elinav E, Chajek-Shaul T. Licorice consumption causing severe hypokalemic paralysis. Mayo Clin Proc. Jun 2003;78(6):767-8. [Medline].

  19. Barrella M, Lauria G, Quatrale R, Paolino E. Hypokaliemic rhabdomyolysis associated with liquorice ingestion: report of an atypical case. Ital J Neurol Sci. Aug 1997;18(4):217-20. [Medline].

  20. van den Bosch AE, van der Klooster JM, Zuidgeest DM, Ouwendijk RJ, Dees A. Severe hypokalaemic paralysis and rhabdomyolysis due to ingestion of liquorice. Neth J Med. Apr 2005;63(4):146-8. [Medline].

  21. Zenone T, Blanc Q. [Rhabdomyolysis with major hypokalemia secondary to chronic glycyrrhizic acid ingestion]. Rev Med Interne. Jan 2009;30(1):78-80. [Medline].

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Further Reading

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Keywords

licorice toxicity, natural licorice, liquorice, licorice extract, licorice root, chronic licorice ingestion, glycyrrhizic acid, GZA toxicology, Glycyrrhiza glabra, 18-beta-glycyrrhetinic acid, GRA, hypermineralocorticoid syndrome, hypermineralocorticoidism, glycyrrhizin

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Contributor Information and Disclosures

Author

Seth Schonwald, MD, FACEP, FACMT, Consulting Staff, Director of Toxicology, Department of Urgent Care, East Boston Neighborhood Health Center
Seth Schonwald, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Massachusetts Medical Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

B Zane Horowitz, MD, FACMT, Professor, Fellowship Director, Department of Emergency Medicine, Oregon Health and Sciences University; Medical Director, Oregon Poison Center; Medical Director, Alaska Poison Control System
B Zane Horowitz, MD, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael Hodgman, MD, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare
Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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