How does liquorice (licorice) affect Erythrocyte Sedimentation Rate (ESR)?

Effect of Licorice on Erythrocyte Sedimentation Rate (ESR)

Licorice consumption can potentially increase ESR values through its anti-inflammatory properties and effects on the cardiovascular system, though this relationship is not directly documented in current literature. While there is no direct evidence specifically measuring the impact of licorice on ESR, we can infer potential effects based on licorice's known pharmacological properties.

Pharmacological Properties of Licorice

• Licorice (Glycyrrhiza uralensis) contains bioactive compounds including glycyrrhizin, glycyrrhetinic acid (GA), liquiritigenin, isoliquiritigenin, licochalcone A, and glycycoumarin 1
• These compounds have documented anti-inflammatory, anti-oxidative stress, immunoregulatory, and anti-fibrotic properties 1
• Traditionally used for multiple purposes including as an anti-inflammatory agent, antitussive expectorant, pain reliever, and diuretic 1

Mechanism of Action Related to Inflammation

• Licorice's active metabolites, particularly glycyrrhetinic acid, inhibit 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) 2, 3
• This inhibition creates an apparent mineralocorticoid excess (AME) syndrome 4
• The anti-inflammatory effects could potentially influence inflammatory markers like ESR, though this specific relationship is not directly documented in the literature

Cardiovascular and Electrolyte Effects

• Regular consumption of moderate amounts of licorice (50-100g daily) can significantly raise blood pressure 2
  • 100g daily consumption raised systolic blood pressure by a mean of 6.5 mmHg 2
  • Even 50g daily consumption raised systolic blood pressure by 5.6 mmHg and diastolic by 3.4 mmHg 2
• Licorice causes sodium retention, potassium loss, and suppression of the renin-angiotensin-aldosterone system 4
• These electrolyte disturbances can lead to hypokalemia, which was documented as a drop of 0.24 mmol/L with 100g daily consumption 2

Potential Impact on ESR

• ESR measures the rate at which red blood cells settle in a tube of blood and is used as a non-specific marker of inflammation
• While there's no direct evidence measuring licorice's effect on ESR specifically, its anti-inflammatory properties could theoretically affect this measurement
• The cardiovascular and fluid retention effects of licorice could potentially influence blood viscosity and plasma proteins, which are factors that affect ESR 5, 4

Clinical Considerations and Cautions

• Long-term use of licorice, especially at high doses, can lead to:
  • Hypertension 1, 2
  • Hypokalemia 6, 5
  • Metabolic alkalosis 6
  • Edema 4
• These complications are due to the mineralocorticoid-like activity of licorice 3
• Some individuals may be more sensitive to licorice's effects than others 3, 5

Recommendations for Clinical Practice

• Be aware that patients consuming licorice may have altered inflammatory markers, though the specific effect on ESR is not well-documented 3, 5
• Consider licorice consumption as a potential factor when interpreting ESR results, especially in patients with unexplained hypertension or hypokalemia 2, 4
• Patients with cirrhosis and those on immunosuppressive medications should avoid licorice due to its mineralocorticoid and drug-drug interaction activities 1
• Healthcare providers should inquire about licorice consumption when evaluating patients with unexplained hypertension or electrolyte abnormalities 5, 4

Common Pitfalls

• Failure to recognize licorice as a potential cause of hypertension and hypokalemia 6, 5
• Overlooking licorice consumption in the patient history when evaluating inflammatory markers 4
• Not considering potential drug interactions, particularly with medications metabolized by CYP3A, such as cyclosporine A, methotrexate, or cilostazol 1