A Case of Pseudoaldosteronism Caused by Tokakujokito During Receiving Insulin

Abstract

A 51-­year-­old woman with a 10-­year history of diabetes visited our clinic for treatment of stiff shoulder and constipation. She was 156 cm tall and weighed 68 kg. The blood pressure was normal. Physical examination revealed no significant abnormalities. After she took the usual amount of tokakujokito for 3 days, hypertension and facial edema, legs edema, weight gain, and headache were observed. Pseudoaldosteronism inhibits 11 β-­hydroxysteroid dehydrogenase Type 2, which is an active glycyrrhizin (GL) and its metabolites glycyrrhizic acid, 3-­monoglucuronyl-­glycyrrhizic acid metabolize and inactivate cortisol to cortisone. As a result, excessive cortisol acts on the mineralocorticoid receptor and promotes sodium reabsorption and excretion of potassium (K+), resulting in water retention and hypokalemia in the body. Insulin also causes hypokalemia because it also takes K+ at the same time as it takes blood glucose in the cell. As a result of these two different processes, it was thought that pseudoaldosteronism developed in low dose licorice. Glycyrrhizin-­containing preparation should be careful used in patients receiving insulin.