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Abstract: SA-PO486

A Case of Licorice Root Toxicity With Hypokalemia-Induced Bradycardia and Hypotension

Session Information

Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders

  • 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical


  • Sakya, Judy, Christ Hospital, Cincinnati, Ohio, United States
  • Pennekamp, Alexander, Christ Hospital, Cincinnati, Ohio, United States

Licorice (glycyrrhetinic acid) toxicity causes hypertension along with hypokalemia by mimicking a state of hyperaldosteronism. It inhibits type 2 11-beta-hydroxysteroid dehydrogenase and binds to mineralocorticoid receptors.

Case Description

A 75-year-old male with a past medical history significant for controlled hypertension, hyperlipidemia, coronary artery disease presented with progressive fatigue and dyspnea on exertion. In the ED, he was hypotensive and bradycardic, hypokalemic with ST-depressions and U-waves on EKG; his troponins were elevated.
His medications prior to admission included: losartan, chlorthalidone.
Serum Creatinine: 1.4 mg/dL (reference: 0.50 - 1.30 mg/dL)
Serum potassium: 1.2 (reference: 3.5 - 5.1 mmol/L)
Urine potassium: 50 (reference: 12.0 - 129.0 mmol/L; inappropriately high)
Urine creatinine: 128.5 mg/dL (reference: 30 - 310 mg/dL)
Fractional excretion of potassium: 45.4% (Renal potassium wasting)
Upon further questioning, patient revealed that he had been taking licorice root extract (glycyrrhetinic acid) for the past three weeks to treat his fatigue. He stated that a provider had mentioned that his fatigue may be a result of possible adrenal insufficiency. To intervene with a natural supplement, he was recommended to take the licorice root extract from an online store. The patient's blood pressure normalized with electrolyte correction, licorice discontinuation and supportive care.


Licorice (glycyrrhetinic acid) is a common addition to many candies, gums, and beverages and small amount of consumption poses minimal risk. Ingestion high enough to produce hypermineralocorticoid effects is possible when consumed as a licorice concentrate - a “health supplementation” that is readily accessible to patients without regulation. Interestingly, in our case, the expected hypertension due to overactivation of the renin-angiotensin-aldosterone system was masked by reduced cardiac output from hypokalemia-induced bradycardia. A detailed history was the key to exploring further urine studies, and an inappropriately high urine potassium and high fractional excretion of potassium confirmed the diagnosis.