Liquorice Toxicity: A Not-So-Sweet Side of a Beloved Treat

What Is Liquorice?

Licorice or liquorice is a herb that grows in various parts of Europe and Asia. It is widely used as a sweetener in many soft drinks, snacks, herbal medicines, and other food products. However, it is a traditional belief that licorice is a healthy natural substance, leading to its consumption that can be occasionally hazardous.

Glycyrrhizin is the primary component of licorice which can lead to harmful side effects if taken in excessive amounts. However, many candies marketed as licorice have artificial licorice flavoring. They do not contain glycyrrhizin; the same applies to licorice root sold as a dietary supplement. These products are termed deglycyrrhizinated licorice or DGL.

What Are the Uses of Liquorice?

Licorice has various uses, which are mentioned below -

• Licorice flavor can be found in various candies, such as

• Licorice sticks and toffee bars.

• Pontefract cakes.

• Stimorol chewing gums.

• It can also be found in soft drinks, such as root beer and herbal teas.

• Licorice extract is available as powder, blocks, or liquid, which can be applied to cigarette tobacco to enhance and soften the flavor and improve the moisture-holding property of tobacco.

Licorice or liquorice is an old age plant that has also been used as a medicinal agent by various sculptures, such as in China and Egypt. Some of its medicinal uses include -

• Cough suppression.

• Gastric ulcer treatment.

• Treatment of early Addison disease (a condition in which adrenal glands do not produce enough hormone).

• Treatment of liver disease.

• As a laxative.

• Dementia (a group of diseases causing memory loss and judgment) symptom treatment.

What Is the Pathophysiology of Liquorice Toxicity?

• Licorice toxicity is rare, but regular licorice ingestion can lead to various harmful effects, such as hypokalemia (excessive potassium loss in the urine) and hypernatremia (high sodium levels in the blood). Natural licorice comprises mineralocorticoid and glucocorticoid properties because of the glycyrrhizin in liquorice. Consumption of large doses of glycyrrhizin in licorice extract can lead to hypokalemia and hypertension, termed hypermineralocorticoidism syndrome. However, the effects of hypermineralocorticoidism syndrome go away upon withdrawal of licorice or glycyrrhizin.

• In the kidneys, the exchange of ions (sodium, potassium, and hydrogen) gets disturbed in the nephrons, which increases extracellular volume, causing conditions like hypertension, edema, hypokalemia, weakness, muscle spasm, and metabolic alkalosis.

• Licorice consumption can even reduce serum testosterone levels. Therefore, it can be used as adjuvant therapy for hirsutism and polycystic ovary syndrome.

What Are the Symptoms of Liquorice Toxicity?

People who consume high amounts of natural licorice products daily are usually affected by chronic licorice toxicity. Symptoms of licorice toxicity include -

• Fatigue and muscle cramping.

• Dark urine.

• Weakness due to hypokalemia (excessive potassium loss in the urine) and myopathies.

• Polyuria (excessive urination), nocturia (frequent nighttime urination).

• Edema.

• Dyspnea (pulmonary edema).

• Headache due to hypertension.

• Paresthesias (burning sensations of extremities).

• Impotence and diminished libido.

• Amenorrhea (absence of menstruation).

How to Diagnose Liquorice Toxicity?

Upon physical examination by the health care professional, the following findings can be noted such as -

• Edema.

• Dangerously high blood pressure, with symptoms such as headache and nausea.

• Vomiting and hypertensive encephalopathy.

• Muscle spasms.

• Hyporeflexia, muscle wasting, and weakness can be found.

• Trousseau (characterized by the appearance of a carpopedal spasm) and Chvostek signs (the twitching of the facial muscles in response to tapping over the area of the facial nerve) from hypokalemia with alkalosis.

• Cardiac arrest, dysrhythmias (rare) from hypokalemia.

These are the common findings that help in the diagnosis of liquorice toxicity.

In addition to all these findings, diagnosis is generally confirmed by a combination of tests to determine hypokalemia, increased urinary free cortisol, elevated cortisol-cortisone metabolite ratio, and low or absent urinary aldosterone. In patients with hypertension, a low serum potassium level is the most helpful test that helps determine mineralocorticoid excess in patients. However, an elevated urinary potassium level may also be present.

Some of the diagnostic tests include -

1. Chest X-rays - If clinically indicated, chest radiography may be performed to assess for pulmonary edema.

2. Urine Tests - Patients with liquorice toxicity usually have high urine aldosterone levels with evidence of hypermineralocorticoidism. Determining urine cortisol levels (often elevated) and cortisol-cortisone metabolite ratios (often elevated) may be helpful.

3. Electrocardiography - This test can be performed to evaluate for hypokalemic changes.

4. Pulse Oximetry and Arterial Blood Gas(ABG) - These can be used to evaluate pulmonary edema and respiratory muscle weakness.

What Are the Complications of Liquorice Toxicity?

Complications related to excess liquorice intake involve -

Cardiovascular

• Hypertension.

• Hypertensive encephalopathy.

• Cardiac arrhythmias.

• Heart failure and pulmonary edema.

• Generalized edema.

Neurological

• Hypokalemic myopathy.

• Rhabdomyolysis (muscle disorder).

• Carpal tunnel syndrome.

• Occular deficits.

Electrolyte and renal abnormalities

• Occular deficits.

• Electrolyte and renal abnormalities.

• Hypokalemia.

• Metabolic alkalosis (condition leading to an increase in the body’s pH).

Allergic reactions

• Occupational asthma.

• Contact dermatitis.

Drug interaction

• Digoxin toxicity due to licorice-induced hypokalemia.

What Are the Drug Interactions of Liquorice?

Liquorice may interact with various drugs, which are mentioned below -

ACE (angiotensin-converting enzyme) inhibitors and diuretics:If patients take angiotensin-converting enzyme (ACE) inhibitors or diuretics for high blood pressure, they should not use licorice products. Licorice can inhibit the actions of these medicines or could cause serious side effects, including a build-up of potassium in the body. ACE inhibitors include -

• Captopril.

• Benazepril.

• Enalapril.

• Lisinopril.

• Gosinopril.

• Ramipril.

• Perindopril.

• Quinapril.

• Moexipril.

• Trandolapril.

Digoxin: Licorice may cause increased toxic effects of digoxin in the body.

Corticosteroids: Licorice interacts with corticosteroids and can increase the effectiveness of this medication.

Insulin or Drugs for Diabetes: Licorice may affect blood sugar levels.

Laxatives: Licorice may cause loss of potassium in people taking laxatives.

MAO (Monoamine oxidase) Inhibitors: Licorice may cause the effect of these drugs to be stronger.

Oral Contraceptives: Various reports of women experiencing high blood pressure and low potassium levels when they took licorice while on oral contraceptives.

Warfarin: Licorice may inhibit the effect of this blood thinner in the body.

Medications Processed by the Liver: Licorice can inhibit several medications that are being processed by the liver, such as

• Celecoxib.

• Diclofenac.

• Fluvastatin.

• Glipizide.

• Ibuprofen.

• Phenytoin.

• Piroxicam.

• Phenobarbital.

• Secobarbital.

What Is the Treatment for Liquorice Toxicity?

Licorice toxicity usually develops after chronic excessive ingestion. Patients with single acute ingestion will not affect the body. In case of suspected chronic toxicity, electrolytes should be monitored along with cardiac monitoring.

Medicines such as Spironolactone or Triamterene can be prescribed to the patient, which helps in maintaining fluid-electrolyte balance in the body.

Conclusion:

Licorice is a widely used sweetener in various food products and its toxicity develops upon consumption by the patient. While licorice has a rich history of use in traditional medicine and confectionery, its active compound, glycyrrhizic acid, can lead to various health issues when taken in large quantities. Awareness of licorice's potential dangers, moderation in consumption, and consulting with healthcare professionals when experiencing symptoms of licorice toxicity are crucial steps in safeguarding one's health and well-being.