Treatment of Licorice Candy Intoxication
The treatment for licorice candy intoxication primarily involves discontinuation of licorice consumption, potassium supplementation, and blood pressure management in severe cases.
Pathophysiology of Licorice Intoxication
Licorice contains glycyrrhizin (also called glycyrrhizic acid or GZA), which is metabolized in the intestines to glycyrrhetinic acid (GA) and 3β-monoglucuronyl-18β-glycyrrhetinic acid (3MGA). These compounds cause:
- Inhibition of 11β-hydroxysteroid dehydrogenase type 2 in renal tissue 1
- Development of apparent mineralocorticoid excess syndrome 1
- Retention of sodium and water
- Increased potassium excretion
Clinical Presentation
Patients with licorice intoxication typically present with:
- Hypertension (often severe)
- Hypokalemia (sometimes profound, as low as 1.8 mmol/L) 2
- Metabolic alkalosis
- Fluid retention and edema 3
- Muscle weakness that can progress to paralysis in severe cases 2, 4
- Suppressed plasma renin activity and aldosterone levels 2
Treatment Algorithm
1. Immediate Interventions
- Discontinue licorice consumption immediately - This is the most critical first step 1
- Assess severity based on:
- Potassium level (severe if <2.5 mmol/L)
- Presence of muscle weakness/paralysis
- Blood pressure elevation
- ECG changes
2. Potassium Repletion
For severe hypokalemia (<2.5 mmol/L) or symptomatic patients:
- Intravenous potassium chloride (KCl) supplementation
- Monitor serum potassium levels every 4-6 hours initially
- Continue repletion until potassium normalizes
For moderate hypokalemia (2.5-3.0 mmol/L) without symptoms:
- Oral potassium supplementation
- Follow-up measurement within 24 hours
3. Blood Pressure Management
For hypertensive crisis:
- Consider IV antihypertensives if severe hypertension is present
For moderate hypertension:
- Consider spironolactone (mineralocorticoid receptor antagonist) 2
- Initial dose: 25-50 mg twice daily
- Particularly effective as it directly counteracts the mineralocorticoid excess
4. Monitoring and Follow-up
- Monitor electrolytes daily until normalized
- Monitor blood pressure until stabilized
- Be aware that symptoms may persist for up to 2 weeks after discontinuation of licorice 2
Special Considerations
Drug Interactions
- Patients on medications that affect potassium levels require closer monitoring:
- Diuretics
- Corticosteroids
- Fludrocortisone (particularly dangerous combination) 5
High-Risk Populations
- Elderly patients are more susceptible to licorice toxicity
- Patients with pre-existing hypertension
- Patients with heart or kidney disease
- Patients on medications that can interact with licorice (e.g., digoxin, antihypertensives)
Prevention and Patient Education
- Advise patients to limit licorice consumption
- Educate patients about products that may contain natural licorice extract:
- Black licorice candy
- Some herbal teas
- Chewing tobacco
- Herbal remedies for cough and digestive issues 3
Common Pitfalls
- Failure to obtain dietary history - Always ask specifically about licorice consumption in unexplained hypokalemia and hypertension 3
- Premature discontinuation of monitoring - Effects can persist for up to 2 weeks after stopping licorice 2
- Missing licorice in non-obvious sources - Consider licorice in herbal teas, tobacco products, and remedies 3
- Overlooking drug interactions - Particularly with fludrocortisone, which can cause severe hypokalemia when combined with licorice 5