SAT-477 - Licorice-Containing Alcoholic Beverages Causing Hypokalemia, Low Aldosterone, and Hypertension - A Case Series

Background:
Many patients with alcohol use disorder (AUD) commonly suffer from hypokalemia and hypomagnesemia secondary to poor nutritional intake. In addition, patients with AUD can become hypertensive over years due to alcohol’s sympathetic activation and alteration of vascular smooth muscle relaxation due to hypomagnesemia (1). In this case series, we present patients who presented with hypokalemia, low aldosterone, and hypertension due to excessive consumption of licorice containing alcoholic beverages.
Case Presentations:
Patient 1: A 58-year-old female with a long-term history of hypertension and obesity was referred to endocrinology for abnormal labs. On her initial visit, she was found to have a blood pressure of 160/90 mmHg. Her labs showed ACTH 64 pg/mL (RR: 6-50 pg/mL), cortisol 20.7 ug/dL (6.2-19.4 ug/dL) Plasma Renin Activity (PRA) 0.21 ng/mL/hr (RR: 0.167-5.378 ng/mL/hr ), Aldosterone < 1 ng/dL (RR: 0-3.0 ng/dL) and Potassium (K) of 2.8 mmol/L (RR: 3.6-5.2 mmol/L). Cushing’s syndrome and non-classical adrenal hyperplasia (NCAH) screening were negative. The patient stated that she drinks 2-3 gin tonic drinks daily. The brand of the gin was provided and was found to have licorice. After stopping alcohol, K, PRA and blood pressure normalized, and the patient reported losing weight.
Patient 2: A 30-year-old male with a history of hypertension, hepatic steatosis and obesity was referred to endocrinology for persistent hypokalemia and poor sexual function. Labs showed K 3.4 mmol/L, aldosterone < 1 ng/dL, PRA 0.36 ng/mL/hr. The patient disclosed that he drank 10 nips of alcohol daily for 5 years, some of which contained licorice. After stopping alcohol completely, labs normalized to aldosterone 2.3 ng/dL, PRA 1.411 ng/mL/hr, K 4.0 mmol/L. In addition, blood pressure normalized, sexual function improved and patient was able to lose weight.

Discussion:
Licorice root contains glycyrrhizic acid, a compound that competitively inhibits 11-beta hydroxysteroid dehydrogenase type 2 (11β-HSD2) which deactivates cortisol. When 11β-HSD2 is inhibited, cortisol levels rise and activate aldosterone receptors, downregulating aldosterone production, and causing primary aldosteronism-like (PA) effects.

Conclusion:
It is imperative to take a detailed social history in patients with electrolyte imbalances and hypertension as some alcoholic beverages contain licorice. Omitting foods containing licorice can normalize K and cortisol levels and therefore provide better blood pressure and weight control.

References:
1. Puddey, I. B., Mori, T. A., Barden, A. E., & Beilin, L. J. (2019). Alcohol and Hypertension-New Insights and Lingering Controversies. Current hypertension reports, 21(10), 79. https://doi.org/10.1007/s11906-019-0984-1

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