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Drug Interactions between digoxin and licorice

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

digoxin licorice

Applies to: digoxin and licorice

GENERALLY AVOID: Chronic use of licorice may potentiate the risk of digitalis toxicity and other cardiovascular complications in patients treated with cardiac glycosides. Glycyrrhizic acid, a component of licorice, can induce hypokalemia, hypernatremia, edema, hypertension, and suppression of the renin-aldosterone system by virtue of its mineralocorticoid activity. In digitalized patients, electrolyte imbalance such as hypokalemia and hypomagnesemia can lead to arrhythmias, while other chronic effects of glycyrrhizic acid can compromise overall cardiovascular condition. In one case report, an 84-year-old man developed congestive heart failure secondary to digitalis toxicity shortly after he began using a Chinese herbal laxative containing licorice 400 mg and rhubarb 1600 mg three times a day. The patient had mitral regurgitation with atrial fibrillation and had been treated with digoxin and furosemide. He recovered 18 days after stopping both digoxin and the herbal laxative.

MANAGEMENT: Patients should consult a healthcare provider before taking any herbal or alternative medicine. In general, chronic use of licorice and licorice-containing products should be avoided in patients treated with cardiac glycosides.

References (11)
  1. Cumming AM, Boddy K, Brown JJ, et al. (1980) "Severe hypokalaemia with paralysis induced by small doses of liquorice." Postgrad Med J, 56, p. 526-9
  2. Cumming A (1976) "Severe reduction of serum potassium induced by licorice." Nurs Times, 72, p. 367-70
  3. Harada T, Ohtaki E, Misu K, Sumiyoshi T, Hosoda S (2002) "Congestive heart failure caused by digitalis toxicity in an elderly man taking a licorice-containing chinese herbal laxative." Cardiology, 98, p. 218
  4. de Klerk GJ, Nieuwenhuis MG, Beutler JJ (1997) "Lesson of the week: hypokalaemia and hypertension associated with use of liquorice flavoured chewing gum." BMJ, 314, p. 731
  5. Edwards CR (1991) "Lessons from licorice." N Engl J Med, 325, p. 1242-3
  6. Stewart PM, Wallace AM, Valentino R, Burt D, Shackleton CH, Edwards CR (1987) "Mineralocorticoid activity of liquorice: 11-beta-hydroxysteroid dehydrogenase deficiency comes of age." Lancet, 2, p. 821-4
  7. Nielsen I, Pedersen RS (1984) "Life-threatening hypokalaemia caused by liquorice ingestion." Lancet, 1, p. 1305
  8. Rosseel M, Schoors D (1993) "Chewing gum and hypokalaemia." Lancet, 341, p. 175
  9. Clyburn EB, DiPette DJ (1995) "Hypertension induced by drugs and other substances." Semin Nephrol, 15, p. 72-86
  10. Farese RV, Biglieri EG, Shackleton CH, Irony I, Gomez-Fontes R (1991) "Licorice-induced hypermineralocorticoidism." N Engl J Med, 325, p. 1223-7
  11. Elinav E, Chajek-Shaul T (2003) "Licorice consumption causing severe hypokalemic paralysis." Mayo Clin Proc, 78, p. 767-8

Drug and food interactions

Minor

digoxin food

Applies to: digoxin

Administration of digoxin with a high-fiber meal has been shown to decrease its bioavailability by almost 20%. Fiber can sequester up to 45% of the drug when given orally. Patients should be advised to maintain a regular diet without significant fluctuation in fiber intake while digoxin is being titrated.

Grapefruit juice may modestly increase the plasma concentrations of digoxin. The mechanism is increased absorption of digoxin due to mild inhibition of intestinal P-glycoprotein by certain compounds present in grapefruits. In 12 healthy volunteers, administration of grapefruit juice with and 30 minutes before, as well as 3.5, 7.5, and 11.5 hours after a single digoxin dose (0.5 mg) increased the mean area under the plasma concentration-time curve (AUC) of digoxin by just 9% compared to administration with water. Moreover, P-glycoprotein genetic polymorphism does not appear to influence the magnitude of the effects of grapefruit juice on digoxin. Thus, the interaction is unlikely to be of clinical significance.

References (2)
  1. Darcy PF (1995) "Nutrient-drug interactions." Adverse Drug React Toxicol Rev, 14, p. 233-54
  2. Becquemont L, Verstuyft C, Kerb R, et al. (2001) "Effect of grapefruit juice on digoxin pharmacokinetics in humans." Clin Pharmacol Ther, 70, p. 311-6

Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

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