[Hypokalemia due to a liquorice-containing thirst-quencher]. / Pseudohyperaldosteronisme door Arabische dorstlesser.

BACKGROUND: Liquorice consumption can cause pseudohyperaldosteronism and potentially lead to life-threatening complications. Besides correcting hypokalemia and hypertension, finding the triggering factor for pseudohyperaldosteronism is essential to prevent recurrence. CASE DESCRIPTION: A 68-year-old Syrian man presented in the Emergency Department with complaints of fatigue, weakness and exercise-related shortness of breath. Blood tests revealed severe hypokalemia for which suppletion and cardiac rhythm surveillance was necessary. Talking to the patient's son, it occurred that our patient drank copious amounts of Erk Sous, a thirst-quenching drink made from liquorice. The diagnosis pseudohyperaldosteronismwas confirmed by a high level of glycyrrhetinic acid in the patient's urine. After correction of the hypokalemia, our patient recovered successfully. CONCLUSION: Erk Sous is a thirst-quenching drink that can cause pseudohyperaldosteronism. The drink is popular in the Middle East during summer and Ramadan. If a patient from the Middle East presents with hypokalemia and/or hypertension, ask for consumption of Erk Sous.

UPLC-Q-TOF-MS and UPLC-MS/MS methods for metabolism profiles and pharmacokinetics of major compounds in Xuanmai Ganjie Granules.

Xuanmai Ganjie Granules (XMGJ), a widely used Chinese herbal formula in the clinic, is used for treatment of sore throats and coughs. Despite the chemical constituents having been clarifying by our previous studies, both of the metabolism and pharmacokinetic studies of XMGJ are unclear. This study aimed to explore the disposition process of XMGJ in vivo. A sensitive and selective ultra-high performance liquid chromatography with quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS) method was developed to analyze the absorbed components and metabolites in rat plasma and urine after oral administration of XMGJ. A total of 42 absorbed components, including 16 prototype compounds and 26 metabolites, were identified or tentatively characterized in rat plasma and urine after oral administration of XMGJ. Moreover, the pharmacokinetic studies of five compounds of XMGJ were investigated using ultra-high liquid chromatography with tandem mass spectrometry method. The results indicated that liquiritin, harpagoside, glycyrrhetic acid, liquiritigenin, formononetin and their metabolites might be the major components involved in the pharmacokinetic and metabolism process of XMGJ. This research showed a comprehensive investigation of XMGJ in vivo, which could provide a meaningful basis for further material basis and pharmacological as well as toxicological research.

3-Monoglucuronyl glycyrrhretinic acid is a possible marker compound related to licorice-induced pseudoaldosteronism.

One of the most common adverse effects of traditional Japanese kampo and traditional Chinese medicine is pseudoaldosteronism caused by licorice. In this review, the authors describe the mechanisms of licorice-induced pseudoaldosteronism by the pharmacokinetics of chemical constituents and its metabolites containing licorice. Glycyrrhizin (GL), the main constituent of licorice, is absorbed as glycyrrhetinic acid (GA), which is a metabolite of GL produced by enterobacteria before its release into the circulation. Circulating GA is metabolized in the liver to become 3-monoglucuronyl-glycyrrhetinic acid (3MGA), which is excreted into the bile via multidrug resistance protein 2 (Mrp2). If Mrp2 function is damaged for some reason, 3MGA is secreted from the liver into the circulation, and excreted into the urine via organic anion transporters expressed at the basolateral side of tubular epithelial cells. Circulating GA cannot be excreted into the urine since GA binds highly to serum albumin and thus does not pass through glomerular filtration and is not a substrate of transporters expressed on tubular epithelial cells. Licorice-induced pseudoaldosteronism develops due to the inhibition of type 2 11ß-hydrosteroid dehydrogenase (11ß-HSD2) which results in the accumulation of cortisol in tubular epithelial cells that activate mineral corticoid receptors to stimulate the excretion of potassium that results in hypokalemia. GA, unlike 3MGA, cannot pass through tubular epithelial cells and cannot inhibit the enzyme in the cells. Therefore, 3MGA may be a genuine causative agent for licorice-induced pseudoaldosteronism. When licorice is used, 3MGA in plasma or urine could function as a marker compound to prevent the adverse effects.

3-Monoglucuronyl-glycyrrhretinic acid is a substrate of organic anion transporters expressed in tubular epithelial cells and plays important roles in licorice-induced pseudoaldosteronism by inhibiting 11ß-hydroxysteroid dehydrogenase 2.

Licorice (glycyrrhiza root) has been used as a herbal medicine worldwide with its main active constituent being glycyrrhizin (GL). Licorice sometimes causes adverse effects such as inducing pseudoaldosteronism by inhibiting type 2 11ß-hydroxysteroid dehydrogenase (11ß-HSD2) caused by glycyrrhetinic acid (GA), a major metabolite of GL. In this study we compared the inhibitory effects of GA, GL, and 3-monoglucuronyl-glycyrrhetinic acid (3MGA), another metabolite of GL, on 11ß-HSD2 activity by using microsomes and rat kidney tissue slices. GA, 3MGA, and GL inhibited 11ß-HSD2 in rat kidney microsomes, with IC(50) values of 0.32, 0.26, and 2.2 µM, respectively. However, the inhibitory activity of these compounds was reduced markedly, in the slices, in a medium containing 5% bovine serum albumin. Assays using human embryonic kidney 293 cells with transient transformation in transporter genes showed that 3MGA is a substrate of human organic anion transporter (OAT) 1, human OAT3, and human organic anion-transporting peptide 4C1, whereas GA is not. When GA (100 mg/kg/day) was administered orally for 16 days to Eisai hyperbilirubinemic rats, plasma concentrations and urinary excretion of 3MGA were significantly higher, whereas the activity of 11ß-HSD2 in kidney microsomes was significantly lower compared with Sprague Dawley rats. These results suggest that 3MGA is actively transported into tubules through OATs, resulting in the inhibition of 11ß-HSD2. Because the plasma level of 3MGA depends on the function of hepatic transporters, monitoring 3MGA levels in plasma or urine may be useful for preventing pseudoaldosteronism when licorice or GL is prescribed to patients.

Determination of urinary 18 beta-glycyrrhetinic acid by gas chromatography and its clinical application in man.

A sensitive and quantitative gas chromatographic assay for the determination of 18 beta-glycyrrhetinic acid (18 beta-GA), the main metabolite of glycyrrhizin after oral licorice consumption in human urine, has been developed and validated. For the extraction of 18 beta-GA from urine two Sep-Pak C18 extractions, hydrolysis with Helix pomatia and three liquid-liquid extractions were performed, using 18 alpha-glycyrrhetinic acid (18 alpha-GA) as internal standard. Both 18 beta-GA and internal standard were converted into their pentafluorobenzyl-ester/trimethylsilyl-ether derivatives and detected by flame ionization detection using a WCOT-fused-silica capillary column. Good quality control data were obtained in precision and accuracy tests. The detection limit of the gas chromatographic method was 10 micrograms/l with a urine volume of 10 ml. A detection limit of 3 micrograms/l was obtained by performing GC-MS. The GC method was used to monitor the urinary excretion of 18 beta-GA after licorice consumption by two healthy volunteers and a patient suspected of licorice abuse. Furthermore, it was shown that this GC assay enables to detect other metabolites related to licorice consumption.

Gas chromatographic-mass spectrometric analysis of urinary glycyrrhetinic acid: an aid in diagnosing liquorice abuse.

OBJECTIVES: Liquorice abuse can lead to severe clinical complications, caused by its active compound 18beta-glycyrrhetinic acid (18betaGA). 18betaGA inhibits dehydrogenase activity of 11beta-hydroxysteroid dehydrogenase (11betaHSD). This enzyme catalyses the interconversion between cortisol and cortisone and normally protects the mineralocorticoid receptor from being activated by cortisol. Diagnosing liquorice abuse can be notoriously difficult. The aim of our study was to develop an accurate and clinically applicable 18betaGA urinary assay. DESIGN: We developed a urinary 18betaGA assay based on gas chromatography and mass spectrometry (GCMS) with sufficient sensitivity to detect 18betaGA at low concentrations. The assay was validated in four volunteers consuming different amounts of liquorice. We applied its use in two patients with hypokalaemic hypertension and suppressed plasma renin activity and serum aldosterone, who were suspected of liquorice abuse. RESULTS: The detection limit for 18betaGA of the GC assay was 10 microg L-1, which was lowered to 3 microg L-1 by subsequent application of MS. In all volunteers, urinary 18betaGA was detected during liquorice intake. Urinary 18betaGA remained detectable until 5 days after stopping continued liquorice intake and until at least 51 h after ingestion of a single large amount. Urinary 18betaGA was demonstrated in both patients, establishing a diagnosis of liquorice abuse. One patient showed changes in urinary cortisol metabolites, consistent with 11betaHSD inhibition. Changes in cortisol metabolites were less pronounced in the other patient. CONCLUSION: Liquorice abuse can result in hypokalaemic hypertension with prolonged suppression of plasma renin activity and aldosterone concentration. This is caused by 18betaGA-mediated inhibition of 11betaHSD, resulting in activation of the renal mineralocorticoid receptor by cortisol. Urinary 18betaGA measurement by GCMS is a useful aid in establishing liquorice abuse.

Determination of glycyrrhizic acid and 18-beta-glycyrrhetinic acid in biological fluids by micellar electrokinetic chromatography.

A micellar electrokinetic chromatographic technique for determining acid (GZA) and 18 beta-glycyrrhetinic acid (GRA) in human plasma and urine was developed. Sample clean-up and analyte concentration were carried out by solid-phase extraction (with C18 sorbent). The buffer solution used for MEKC contained 20 mM sodium dihydrogenphosphate, 20 mM sodium tetraborate, 20 mM tetrabutylammonium bromide and 50 mM sodium dodecylsulphate, at a pH of 8.7. Good linearities for both GZA and GRA in plasma and urine were obtained. The recoveries of the method were in the range 86.5 to 107%. The detection limits for GZA in urine (0.5 ml) and plasma (1 ml) were 1.6 micrograms ml-1 and 0.8 micrograms ml-1, respectively, while for GRA in urine (0.5 ml) and plasma (1 ml) were 2 micrograms ml-1 and 1 micrograms ml-1, respectively.

Impact of dietary Na+ on glycyrrhetinic acid-like factors (kidney 11beta-(HSD2)-GALFs) in human essential hypertension.

Our previous studies have shown that human urine contains glycyrrhetinic acid-like factors (GALFs) that possess inhibitory activity against kidney 11beta-hydroxysteroid dehydrogenase isoform 2 (HSD2). The present studies were undertaken to determine the impact of dietary Na+ intake on the levels of kidney 11beta(HSD2)-GALFs. The excretion of kidney 11beta(HSD2)-GALFs in 24-hour urine samples of 30 unmedicated subjects (10 normotensive and 10 high/normal-renin and 10 low-renin essential hypertensive subjects) on both 200- and 10-mmol Na+ diets was studied. No differences in the urinary levels of kidney 11beta(HSD2)-GALFs were observed among the three groups on the high-Na+ diet. However, with a low-Na+ diet, the levels of kidney 11beta(HSD2)-GALFs were significantly increased in hypertensive subjects but not in normal subjects. Levels increased from 8.3+/-1.4 to 17.3+/-2.9 and 6.7+/-1.3 to 10.6+/-1.4 carbenoxolone sodium units/d in high/normal-renin (P=.01) and low-renin hypertensive subjects (P=.07), respectively; normal subjects changed from 8.0+/-1.9 to 10.6+/-2.4. The levels of kidney 11beta(HSD2)-GALFs were significantly higher in the high/normal-renin hypertensive subjects than in either the control normotensive subjects or the low-renin hypertensive subjects when challenged with the low-Na+ diet (P<.05 by Wilcoxon rank-sum test). The greater response of the high/normal-renin essential hypertensive subjects indicated that they may utilize kidney 11beta(HSD2)-GALFs when challenged with a low-Na+ diet, whereas the low-renin essential hypertensive subjects do not.

Kidney 11 beta-HSD2 is inhibited by glycyrrhetinic acid-like factors in human urine.

We have previously shown that human urine contains substances that, like glycyrrhetinic acid, inhibit 11 beta-HSD1. We have named these substances "glycyrrhetinic acid-like factors" or GALFs. We now have found that human urine contains measurable quantities of both 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory substances. Both are markedly elevated in pregnancy. Their chemical and high-performance liquid chromatography (HPLC) characteristics suggest that several of the GALFs are steroidal. Large quantities of neutral 11 beta(HSD1)- and 11 beta(HSD2)-GALFs can be extracted directly from urine into ethyl acetate, yielding fraction EA1. Hydrolysis of the GALFs remaining in the aqueous phase by beta-glucuronidase markedly increases the total amounts of GALFs, with the majority now being ethyl acetate extractable (fraction EA2). These EA2 post-hydrolysis GALFs can be separated by HPLC resulting in at least six components with inhibitory activity against each isoenzyme. Only two GALF peaks are active against both 11 beta-HSD1 and 11 beta-HSD2. The others are peaks with specific 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory activity. The GALFs in the same posthydrolysis EA2 extract are also inhibitory toward the 11 beta-HSD1 that is present in vascular smooth muscle where they may play a role in the mechanisms controlling blood pressure. We have also found that 11 beta-HSD2 is selectively inhibited by 5 alpha- (but not by 5 beta-) reduced steroids. GC-MS analysis of the 11 beta(HSD2)-GALFs in EA2 is now being performed to determine whether this group includes 3 alpha,5 alpha-ring A-tetrahydro-reduced derivatives of steroids.

Interaction of licorice on glycyrrhizin pharmacokinetics.

The effects of components of aqueous licorice root extract (LE) on the pharmacokinetics of glycyrrhizin (G) and glycyrrhetic acid (GA) were investigated in rats and humans. The aim of this work was to define the role of pharmacokinetics in G toxicity. In the procedure, G and GA were detected in biological fluids by means of recently improved HPLC methods. Significantly lower G and GA plasma levels were found in rats and humans treated with LE compared to the levels obtained with those in which G alone was administered. The pharmacokinetic curves showed significant differences in the areas under the plasma-time curve (AUC), Cmax, and Tmax parameters. The data obtained from urine samples are in agreement with the above results and confirm a reduced bioavailability of G present in LE compared to pure G. This should be attributed to the interaction during intestinal absorption between the G constituent and the several components in LE. The modified bioavailability could explain the various clinical adverse effects resulting from the chronic oral administration of G alone as opposed to LE.

Inhibitors of 11 beta-hydroxysteroid dehydrogenase and 5 beta-steroid reductase in urine from patients with congestive heart failure.

Recently, the current authors reported the presence in normotensive male and female urines of reproducibly measurable levels of naturally occurring substances in partially purified extracts of urine with inhibitory activity like glycyrrhetic acid (GA) towards both 11 beta-hydroxysteroid dehydrogenase (11 beta-OHSD) and steroid 5 beta-reductase (5 beta-SR) in vitro. Since these substances mimic two known inhibitory activities of GA, they have been named 'Glycyrrhetic Acid-Like Factors', abbreviated as 'GALFs' or, more specifically 11 beta-GALF for substance(s) active against 11 beta-OHSD, and 5 beta-GALF for those inhibitory to 5 beta-SR. Administration of glycyrrhetic acid in man leads to cortisol-dependent mineralocorticoid hypertension, owing to impaired inactivation of cortisol by 11 beta-OHSD, and may be associated with increased sensitivity to mineralocorticoids owing to impaired 5 beta-SR. In this preliminary report, the results are described of a study on the presence of GALF factors in urines collected from patients with congestive heart failure (CHF) and mild essential hypertension. The results show that in such patients there are increased amounts of both 11 beta- and 5 beta- GALFs compared to normotensive. The possible physiological significance of these results is discussed.

Kinetic analysis of glycyrrhetic acid, an active metabolite of glycyrrhizin, in rats: role of enterohepatic circulation.

The role of enterohepatic circulation of glycyrrhetic acid (GA) in rats was determined by kinetic analysis of GA. The concentrations of GA in the plasma of the control rat (without bile duct cannulation) during the first 5 h after intravenous (iv) administration of GA (2, 5, 10, and 20 mg/kg) were similar to those in the bile duct-cannulated rat at each dose. No significant difference was observed in the values of the terminal half-life, the total body clearance, the distribution volume at steady state, the area under the curve of concentration in plasma versus time, and the mean residence time in each dose between both groups. When GA (2, 5, 10, and 20 mg/kg) was administered i.v. to the bile duct-cannulated rat, excretion of unchanged GA in bile was < 1% of each dose, that of the acid-hydrolyzed products was 14-16%, and that of GA-3-O-glucuronide was only 1-2%. In the control rat, a secondary peak of GA concentration was observed 12 h after i.v. administration of GA (20 mg/kg). The enterohepatic circulation of GA was confirmed by the linked-rat method in which bile of the donor rat after i.v. administration of GA (20 mg/kg) was allowed to flow directly into the duodenum of the recipient rat. GA was found in the plasma of the recipient rat after 6 h, and its concentration reached the maximum (approximately 0.5 microgram/mL) 8-12 h after dosing the donor rat.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of glycyrrhetinic acid-like factors (GALFs) in human urine.

Patients with the syndrome of apparent mineralocorticoid excess and those who ingest licorice show markedly decreased 11 beta-hydroxysteroid dehydrogenase (11 beta-OHSD) and 5 beta-reductase activity; both are important for the deactivation of glucocorticoids and other steroid hormones. Glycyrrhetinic acid (GA), present as its glycoside in licorice, is a potent inhibitor of both 11 beta-OHSD and 5 beta-reductase and, as we have also shown, confers Na(+)-retaining properties on glucocorticoids and amplifies those of aldosterone and deoxycorticosterone. We report the results of our initial studies demonstrating the presence of naturally occurring substances, which inhibit both 5 beta-reductase and 11 beta-OHSD as does GA, in partially purified extracts of urine from normotensive men and nonpregnant and pregnant women. Since these substances exhibit GA-like activity, we have termed them GA-like factors (GALFs). This "inhibitory" material is heat stable and does not react with ninhydrin; the majority is not extractable with ethyl acetate and thus is not a "free" steroid. When further purified by high-performance liquid chromatography with a methanol/water gradient, the majority of these GALFs appeared in two regions of inhibitory activity. The chemical nature of this material is currently being investigated. These experiments indicate that normal human urine contains GALFs that may play a role in Na+ homeostasis and regulation of blood pressure.

Selective high-performance liquid chromatographic method for the determination of glycyrrhizin and glycyrrhetic acid-3-O-glucuronide in biological fluids: application of ion-pair extraction and fluorescence labelling agent.

A selective high-performance liquid chromatographic method has been developed for the simultaneous determination of glycyrrhizin and glycyrrhetic acid-3-O-glucuronide in biological fluids of the rat. The procedure is based on the ion-pair formation using tetra-n-amylammonium bromide, extraction with ethyl acetate-n-heptane from the salt-saturated aqueous phase, labelling with 4-bromomethyl-7-methoxycoumarin, followed by chromatographic separation with fluorescence detection. Glycyrrhizin in plasma, bile and urine could be precisely determined in concentrations as low as 1, 1 and 2.5 micrograms/ml, respectively, in a 0.1-ml sample. The equivalent values for the glucuronide were 1, 2.5 and 2.5 micrograms/ml, respectively. The method is applicable in pharmacokinetic studies of glycyrrhizin in small animals.

Biliary excretion and enterohepatic cycling of glycyrrhizin in rats.

The enterohepatic cycling of glycyrrhizin was examined using rats with and without biliary fistulization. The plasma decay in the control rats without fistulization following an iv dose of 100 mg/kg of glycyrrhizin, was generally biphasic. However, secondary peaks were observed in all rats in the elimination phase, i.e., 0.5 to 12 h following dosing. The plasma concentrations in the rats with biliary fistulization administered the same dose showed a biexponential decline. The AUC and CLtot were significantly higher and lower in the control rats, respectively. The biliary excretion was 80.6 +/- 9.9% of the administered dose, and intestinal absorption was confirmed by using the bile collected after iv dosing. From these results, we concluded that glycyrrhizin was predominantly secreted from the liver into the bile, and that the secondary peaks in the elimination phase, the higher AUC, and the lower CLtot in the control rats were due to the effects of enterohepatic recycling of glycyrrhizin. Furthermore, the transport of the drug from the liver to the bile appears to be a saturable process.

Disposition of glycyrrhetic acid and its glycosides in healthy subjects and patients with pseudoaldosteronism.

As a first step to elucidate the disposition of traditional Chinese formulations which contain licorice, the disposition of plain licorice was investigated in humans. Glycyrrhetic acid (GLA) was measured by an enzyme immuno-antibody technique. Glycyrrhetic glycosides (GLA-GS), such as glycyrrhizin, were measured after acid hydrolysis to GLA by the enzyme immuno-antibody assay. Five normal subjects were orally administered a decoction of licorice containing 133 mg of glycyrrhizin. It was found that the time required for maximum serum concentration of GLA-GS was less than 4 h after the administration. Although there were large individual differences, it was found that GLA-GS was eliminated from the blood for the most part within 72 h. On the other hand, GLA reached maximum serum concentration at about 24 h after administration and in two of the five cases it was still detected in the blood even after 96 h. Urinary excretion of GLA was about 2% of the total dose of glycyrrhizin administered. This suggested that there were great differences among the subjects in the absorption and urinary excretion of GLA-GS. The serum GLA levels in two clinical cases who presented pseudoaldosteronism by licorice containing formulations were as high as 70-80 ng/ml, with GLA-GS levels being very low. This fact suggests that pseudoaldosteronism develops in association with GLA rather than with GLA-GS.