How to manage hyperkalemia suspected to be caused by Minophagen (glycyrrhizin)?

Management of Hyperkalemia Caused by Minophagen (Glycyrrhizin)

For hyperkalemia suspected to be caused by Minophagen (glycyrrhizin), discontinue the medication immediately and initiate potassium-lowering therapy based on severity, with close monitoring of potassium levels until normalization. 1

Understanding the Mechanism

• Glycyrrhizin, found in Minophagen and licorice extract, causes pseudohyperaldosteronism by inhibiting 11β-hydroxysteroid dehydrogenase, leading to increased cortisol activity on mineralocorticoid receptors 1
• This paradoxically results in hypertension and hypokalemia in most cases, but can occasionally cause hyperkalemia through complex mechanisms 1

Initial Management Steps

• Immediately discontinue Minophagen/glycyrrhizin-containing products 1
• Assess severity of hyperkalemia based on potassium levels:
  • Mild: >5.0 to <5.5 mEq/L
  • Moderate: 5.5 to 6.0 mEq/L
  • Severe: >6.0 mEq/L (life-threatening) 2
• Obtain ECG to evaluate for cardiac conduction abnormalities that require urgent intervention 3

Treatment Algorithm Based on Severity

For Severe Hyperkalemia (>6.0 mEq/L) or with ECG Changes:

1. Administer intravenous calcium to stabilize cardiac membranes (onset within minutes, lasts 30-60 minutes) 2
2. Shift potassium intracellularly:
   • Insulin with glucose (onset 15-30 minutes, lasts 4-6 hours) 2
   • Inhaled beta-agonists like albuterol 3
   • Sodium bicarbonate if concurrent metabolic acidosis 2
3. Eliminate potassium from the body:
   • Loop diuretics if renal function is adequate 2
   • Potassium binders (patiromer or sodium zirconium cyclosilicate) 4, 2
   • Consider hemodialysis for life-threatening cases unresponsive to medical therapy 4

For Moderate Hyperkalemia (5.5-6.0 mEq/L):

1. Discontinue Minophagen/glycyrrhizin 1
2. Initiate approved potassium-lowering agents:
   • Newer potassium binders (patiromer or sodium zirconium cyclosilicate) are preferred over sodium polystyrene sulfonate due to better safety profile 2, 5
3. Consider loop or thiazide diuretics to increase potassium excretion 2

For Mild Hyperkalemia (>5.0-<5.5 mEq/L):

1. Discontinue Minophagen/glycyrrhizin 1
2. Closely monitor potassium levels 2
3. Consider potassium-lowering agents if levels don't normalize after discontinuation 2

Monitoring and Follow-up

• Monitor serum potassium levels frequently until normalization 2
• Check for rebound hyperkalemia, especially after acute interventions 3
• Evaluate blood pressure, as glycyrrhizin often causes hypertension that should resolve after discontinuation 1
• Assess renal function, as impaired kidney function can exacerbate hyperkalemia 4

Additional Considerations

• Evaluate other medications that may contribute to hyperkalemia (RAAS inhibitors, potassium-sparing diuretics, NSAIDs) 4, 2
• Review dietary sources of potassium and supplements that may contribute to the condition 2
• Consider underlying conditions that may predispose to hyperkalemia (renal impairment, diabetes, heart failure) 4, 6

Common Pitfalls to Avoid

• Avoid chronic use of sodium polystyrene sulfonate with sorbitol due to risk of bowel necrosis 2
• Don't delay treatment when potassium levels exceed 5.0 mEq/L in high-risk patients 2
• Be aware that polypharmacy (>5 drugs) is a significant predictor of drug-induced potassium disorders 6
• Remember that glycyrrhizin typically causes hypokalemia, so hyperkalemia should prompt investigation for other contributing factors 1