{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T14:17:47Z","timestamp":1789654667233,"version":"4.0.1"},"reference-count":30,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2024,7,7]],"date-time":"2024-07-07T00:00:00Z","timestamp":1720310400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJMS"],"abstract":"<jats:p>Pseudohyperaldosteronism (PHA) is characterized by hypertension, hypokalemia, and a decrease in plasma renin and aldosterone levels. It can be caused by several causes, but the most frequent is due to excess intake of licorice. The effect is mediated by the active metabolite of licorice, glycyrrhetinic acid (GA), which acts by blocking the 11-hydroxysteroid dehydrogenase type 2 and binding to the mineralocorticoid receptor (MR) as an agonist. The management of licorice-induced PHA depends on several individual factors, such as age, gender, comorbidities, duration and amount of licorice intake, and metabolism. The clinical picture usually reverts upon licorice withdrawal, but sometimes mineralocorticoid-like effects can be critical and persist for several weeks, requiring treatment with MR blockers and potassium supplements. Through this case series of licorice-induced PHA, we aim to increase awareness about exogenous PHA, and the possible risk associated with excess intake of licorice. An accurate history is mandatory in patients with hypertension and hypokalemia to avoid unnecessary testing. GA is a component of several products, such as candies, breath fresheners, beverages, tobacco, cosmetics, and laxatives. In recent years, the mechanisms of action of licorice and its active compounds have been better elucidated, suggesting its benefits in several clinical settings. Nevertheless, licorice should still be consumed with caution, considering that licorice-induced PHA is still an underestimated condition, and its intake should be avoided in patients with increased risk of licorice toxicity due to concomitant comorbidities or interfering drugs.<\/jats:p>","DOI":"10.3390\/ijms25137454","type":"journal-article","created":{"date-parts":[[2024,7,8]],"date-time":"2024-07-08T12:21:03Z","timestamp":1720441263000},"page":"7454","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Pseudohyperaldosteronism Due to Licorice: A Practice-Based Learning from a Case Series"],"prefix":"10.3390","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1526-6832","authenticated-orcid":false,"given":"Chiara","family":"Sabbadin","sequence":"first","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Graziani","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Bavaresco","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pierluigi","family":"Mazzeo","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4092-5107","authenticated-orcid":false,"given":"Irene","family":"Tizianel","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Filippo","family":"Ceccato","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6433-5155","authenticated-orcid":false,"given":"Decio","family":"Armanini","sequence":"additional","affiliation":[{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1081-5727","authenticated-orcid":false,"given":"Mattia","family":"Barbot","sequence":"additional","affiliation":[{"name":"Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy"},{"name":"Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,7,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1080\/713609355","article-title":"Pseudohyperaldosteronism: Pathogenetic Mechanisms","volume":"40","author":"Armanini","year":"2003","journal-title":"Crit. Rev. Clin. Lab. Sci."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1007\/s40292-016-0160-5","article-title":"Syndromes that Mimic an Excess of Mineralocorticoids","volume":"23","author":"Sabbadin","year":"2016","journal-title":"High Blood Press. Cardiovasc."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Sabbadin, C., Bordin, L., Don\u00e0, G., Manso, J., Avruscio, G., and Armanini, D. (2019). Licorice: From Pseudohyperaldosteronism to Therapeutic Uses. Front. Endocrinol., 10.","DOI":"10.3389\/fendo.2019.00484"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"6219","DOI":"10.2174\/0929867325666191011115407","article-title":"Advances in Pharmacological Activities and Mechanisms of Glycyrrhizic Acid","volume":"27","author":"Chen","year":"2020","journal-title":"Curr. Med. Chem."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1142\/S0192415X24500289","article-title":"A Comprehensive Review of Licorice: The Preparation, Chemical Composition, Bioactivities and Its Applications","volume":"52","author":"Ji","year":"2024","journal-title":"Am. J. Chin. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.ejogrb.2006.10.013","article-title":"Treatment of polycystic ovary syndrome with spironolactone plus licorice","volume":"131","author":"Armanini","year":"2007","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"111727","DOI":"10.1016\/j.nut.2022.111727","article-title":"Effects of licorice on sex hormones and the reproductive system","volume":"103\u2013104","author":"Minnetti","year":"2022","journal-title":"Nutrition"},{"key":"ref_8","first-page":"e16454","article-title":"How Much Is Too Much? Exploring Pseudohyperaldosteronism in Glycyrrhizic Acid Toxicity from Chronic Licorice Root Consumption","volume":"13","author":"Patel","year":"2021","journal-title":"Cureus"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1007\/BF03349993","article-title":"Mineralocorticoid effector mechanism of licorice derivates in human mononuclear leukocytes","volume":"12","author":"Armanini","year":"1989","journal-title":"J. Endocrinol. Investig."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1177\/2042018812454322","article-title":"Licorice abuse: Time to send a warning message","volume":"3","author":"Omar","year":"2012","journal-title":"Ther. Adv. Endocrinol. Metab."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1517\/14656566.2014.896901","article-title":"Aldosterone receptor blockers spironolactone and canrenone: Two multivalent drugs","volume":"15","author":"Armanini","year":"2014","journal-title":"Expert. Opin. Pharmacother."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1038\/jhh.2017.45","article-title":"The association between consistent licorice ingestion, hypertension and hypokalaemia: A systematic review and meta-analysis","volume":"31","author":"Penninkilampi","year":"2017","journal-title":"J. Hum. Hypertens."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1016\/S0889-8529(18)30102-6","article-title":"Licorice-induced hypertension and syndromes of apparent mineralocorticoid excess","volume":"23","author":"Walker","year":"1994","journal-title":"Endocrinol. Metab. Clin. North. Am."},{"key":"ref_14","unstructured":"Bijlsma, J., Van Vloten, P., Van Gelderen, C., Mensinga, T., Mout, H., Elvers, L., Van Leeuwen, F.X.R., Stolker, A.A.M., Van Ginkel, L.A., and Looman, C.W.N. (1996). Study into the Effects of Different Dosages of Glycyrrhizin in Health Female Volunteers, (In Dutch)."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Yoshino, T., Shimada, S., Homma, M., Makino, T., Mimura, M., and Watanabe, K. (2021). Clinical Risk Factors of Licorice-Induced Pseudoaldosteronism Based on Glycyrrhizin-Metabolite Concentrations: A Narrative Review. Front. Nutr., 8.","DOI":"10.3389\/fnut.2021.719197"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"3021","DOI":"10.1093\/eurheartj\/ehy339","article-title":"2018 ESC\/ESH guidelines for the management of arterial hypertension","volume":"39","author":"Williams","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1080\/08037050600593060","article-title":"The Liquorice Effect on the RAAS Differs between the Genders","volume":"15","author":"Sigurjonsdottir","year":"2006","journal-title":"Blood Press."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Ceccuzzi, G., Rapino, A., Perna, B., Costanzini, A., Farinelli, A., Fiorica, I., Marziani, B., Cianci, A., Rossin, F., and Cesaro, A.E. (2023). Liquorice Toxicity: A Comprehensive Narrative Review. Nutrients, 15.","DOI":"10.3390\/nu15183866"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1038\/ajh.2008.152","article-title":"Age-dependent decrease in 11beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2) activity in hypertensive patients","volume":"21","author":"Henschkowski","year":"2008","journal-title":"Am. J. Hypertens."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/0303-8467(93)90089-Y","article-title":"Hypertension encephalopathy after liquorice ingestion","volume":"95","year":"1993","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1016\/j.pediatrneurol.2014.12.001","article-title":"Posterior Reversible Encephalopathy Syndrome Associated with Licorice Consumption: A Case Report in a 10-Year-Old Boy","volume":"52","author":"Tassinari","year":"2015","journal-title":"Pediatr. Neurol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1186\/s12967-022-03698-9","article-title":"Apparent mineralocorticoid excess: Comprehensive overview of molecular genetics","volume":"20","author":"Lu","year":"2022","journal-title":"J. Transl. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"300060518811058","DOI":"10.1177\/0300060518811058","article-title":"Electrocardiographic manifestations in severe hypokalemia","volume":"48","author":"Wang","year":"2020","journal-title":"J. Int. Med. Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"887","DOI":"10.1080\/00015385.2020.1799573","article-title":"Low serum potassium levels are associated with the risk of atrial fibrillation","volume":"76","author":"Farah","year":"2021","journal-title":"Acta Cardiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1161\/CIRCRESAHA.119.315641","article-title":"Hypokalemia Promotes Arrhythmia by Distinct Mechanisms in Atrial and Ventricular Myocytes","volume":"126","author":"Tazmini","year":"2020","journal-title":"Circ. Res."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Deutch, M.R., Grimm, D., Wehland, M., Infanger, M., and Kr\u00fcger, M. (2019). Bioactive Candy: Effects of Licorice on the Cardiovascular System. Foods, 8.","DOI":"10.3390\/foods8100495"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"207","DOI":"10.5694\/mja2.50728","article-title":"The dangers of herbal teas: Hypertension and weakness caused by liquorice-induced apparent mineralocorticoid excess","volume":"213","author":"Pandher","year":"2020","journal-title":"Med. J. Aust."},{"key":"ref_28","first-page":"135","article-title":"11 beta-Hydroxysteroid dehydrogenase and the syndrome of apparent mineralocorticoid excess","volume":"18","author":"White","year":"1997","journal-title":"Endocr. Rev."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1111\/j.1365-2796.1989.tb00046.x","article-title":"Effects of licorice on plasma atrial natriuretic peptide in healthy volunteers","volume":"225","author":"Forslund","year":"1989","journal-title":"J. Intern. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1007\/s13555-019-00319-0","article-title":"Topical Non-Pharmacological Treatment for Facial Seborrheic Dermatitis","volume":"9","author":"Hexsel","year":"2019","journal-title":"Dermatol. Ther."}],"container-title":["International Journal of Molecular Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1422-0067\/25\/13\/7454\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:11:19Z","timestamp":1760109079000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1422-0067\/25\/13\/7454"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,7,7]]},"references-count":30,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2024,7]]}},"alternative-id":["ijms25137454"],"URL":"https:\/\/doi.org\/10.3390\/ijms25137454","relation":{},"ISSN":["1422-0067"],"issn-type":[{"value":"1422-0067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,7,7]]}}}