Which candy additive to chewing tobacco or liquor can cause a syndrome mimicking mineralocorticoid excess and what is the mechanism?
Individuals ingesting large amounts of high-quality licorice, which contains glycyrrhetinic acid, can develop hypertension associated with hypokalemia and metabolic alkalosis. This condition resembles an acquired form of AME. Glycyrrhetinic acid inhibits 11β-hydroxysteroid dehydrogenase 2 (11-β-HSD 2), thereby increasing cortisol in the distal tubule cells in the kidney, activating MR and increasing sodium reabsorption similar to that which occurs in AME syndrome. A frequently aggravating factor can be high salt content of certain licorice brands. Glycyrrhetinic acid can also be found in chewing tobacco, anise liquors (Ouzo, Arak, Raki, Sambuca), and carbenoxolone, a synthetic analog that is licensed in the United Kingdom for treatment of mucosal ulcerations.