GAN CAO INTERACTIONS& CAUTIONS SHEET

 Common Western name: Liquorice

 Chinese Name: Gān Căo
 Latin Binomial: Glycyrrhizae Radix
 Dosage: 1.5 to 9g

WESTERN MEDICAL FUNCTIONS & INDICATIONS

 Demulcent (sore throats)

 Expectorant (coughs and bronchial phlegm)
 Pain relief (gastric and duodenal ulcers, and dyspepsia)
 Anti-inflammatory (allergic reactions, rheumatism and arthritis

 Reduces toxicity
 Treats Adrenocorticoid insufficiency

CHINESE MEDICAL FUNCTIONS & INDICATIONS

 Up regulates Spleen function and reinforces Qi

(Shortness of breath, lassitude and loose stools)
 Nourishes the Lungs and stops cough
(Cough and wheezing)
 Moderates spasms and alleviates pain
 Clears Heat and eliminates toxins, acts as antidote for toxic substances and harmonizes
other herbs
(Sore throat, carbuncles, sores all due to Fire toxicity)

ACTIVE CONSTITUENTS

There are hundreds of active constituents contained in liquorice however here are the
most important.

 Contains approximately 6% Triterpene Saponins responsible for the herbs sweet taste
and for this herb’s main adverse reactions. (Huang, K, 1999, p.354)

IMPORTANT WESTERN MEDICAL

CONCIDERATIONS(INCOMPATIBILITIES)

 Steroidal anti-inflammatory drugs (Cortisone)

 Blood thinners (Warfarin)
 ACE inhibitors (Accupril)
 Diuretics (thiazide)
 Cardiac glycosides

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 This herb can alter the therapeutic effect corticosteroids class of anti-inflammatory
drugs, therefore in patients taking cortisone, prednisone or dexamethasone, caution
should be taken for 3 reasons.
1. Gān Căo may increase the half-life of corticosteroids by suppressing its metabolic
breakdown. (Sperder, 2013) (Syrian Clinic, 2000). It has been found that, In vitro,
glycyrrhetic acid inhibits Δ4β-reductase, an enzyme that competitively inactivates
corticosteroids. (WHO, 2017) This results in higher plasma concentrations above the
therapeutic dose with side effects such as hypertension, convulsion, edema, nervousness,
weakness, burning sensations and psychosis.
2. Glycyrrhizin and glycyrrhizinic acid have a moderate binding effect, acting as an
agonist on glucocorticoid and mineralocorticoid receptors (Miyamori, 1987).
3. Glycyrrhizin inhibits conversion of cortisol to cortisone by directly inhibiting renal 11-
Beta OHSD. This serves to explain the plants anti-inflammatory function in naturopathic
medicine.

It would be best to talk with the patient’s PG before prescribing Gān Căo in such cases.
However according to Huang, concurrent Gān Căo ingestion may potentiate and
prolong the action of cortisol (Huang, 1999, p.366). This may mean that if moderated
properly a lower dosage of cortisol may be required in order to maintain a desirable
therapeutic effect with fewer of the above side effects.

This class of drug may reduce potassium levels therefore when combined with Gān Căo
may have the effect of inducing hypokalemia (RxList, 2016) resulting in such symptoms
as hypertension, diarrhea, fatigue, irregular heart beat and reduced reflexes (Right
diagnosis, 2106)
 Warfarin has a major interaction with Gān Căo and the concurrent prescription of these
is contraindicated (RxList, 2016). Gān Căo may increase the breakdown/metabolism of
warfarin via increasing efficiency of first pass metabolism which will reduce its
therapeutic effect and in turn increases its required therapeutic dose. Therefore, if a
patient is on warfarin while regularly consuming Gān Căo and does not disclose this
information while their treating PG is working on moderating the patient dosage. Then
the required therapeutic dose will be affected meaning that more of the drug may be
required. If the patient then ceases intake of Gān Că0 then there is a chance of over
dosage. This is important because warfarin has a narrow therapeutic window meaning
that there is only a small margin between a therapeutic dosage and over dosage with
associated bleeding disorders such as easy bruising, haematuria, haemafecia,
haemoptysis, headaches and occult bleeding (nps, 2016).

 ACE aka angiotensin converting enzyme inhibitors are a major source of negative
interaction (UMMC, 2016). Combining ACE inhibiters with Gān Căo will result in
hyperkalaemia with symptoms of muscle weakness, paralysis and arrhythmias
(McCance, K, 2010, p.110) ACE inhibitors function to induce a decrease in blood volume
along with stroke volume as a means of reducing blood pressure via reducing the
sympathetic response and promoting vasodilation. This is achieved via inhibition of the
enzyme (Renin) which converts angiotensinogen to angiotensin I and II that in turn
stimulates aldosterone secretion to bring about the retention of sodium at the expense of
potassium within the tubules of the Kidneys. Therefore, ACE inhibitors causes a loss of
sodium and blood volume in order to lower blood pressure (Flaws, B, 2014, p. 130). Gān
Căo may increase blood pressure by the same mechanism involved in pseudo secondary
mineralocorticoid hyperaldosteremia therefore this herb should be cautioned in patients
prescribed ACE inhibitors (Flaws, B, 2014, p.132).

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  Due to the aforementioned potassium loss, prolonged use of thiazide and loop diuretics
(WHO, 2017). Consumption of these may result in lower blood pressure, postural
dizziness, feeling faint, muscle cramps, drowsiness and nausea (Drugs.com, 2017).

IMPORTANT CONTARINDICATIONS
 Hypertension
 Edema
 Nausea
 Heart pathologies

 Due to Gān Căo containing the constituent glycyrrhizinic acid, over consumption may
result in pseudo secondary mineralocorticoid hyperaldosteremia (Winston, 2007, p. 175),
involving the retention of sodium, potentially leading to (hypernatremia) and excretion
of potassium (Hypokalemia). This may result in hypercalcemia, fatigue, edema,
hypertension, headache, transient paralysis, weakness and numbness (Medscape, 2016).
Gān Căo therefore is contraindicated among patients experiencing hypertension,
edema and nausea (Penner, 2016) (Huang, K, 1999, p.366). Edema is aggravated or
caused due to the same mechanism as in the case of pseudo secondary mineralocorticoid
hyperaldosteronism where sodium levels increase with the consequence increased
retention of water as a means to balance out the high sodium levels. Here sodium causes
a build-up of interstitial fluids which places a greater hemodynamic burden on the heart
therefor Gān Căo is also cautioned in Heart pathologies.

Traditionally Gān Căo is contraindicated or cautioned in edema due to the herbs “cloying” property
where it is said to cause a pooling of Qi and also therefore fluids to result in edema and nausea.

 Hypertension: Glycyrrhizinic acid deactivates the HSD-11β enzyme which breaks down
cortisol (Robert, 1991), therefore cortisol levels increase, triggering the aldosterone
potassium feedback loop as cortisol mimics the same effects of the mineralocorticoid
hormone aldosterone with regard to blood volume modulation, thus the term pseudo
hyperaldosteronism. This occurs due to glycyrrhizinic acid and cortisol sharing the same
receptor site located in the epithelial tissue of the Kidneys and results in a false increase
in cortisol with consequent net reduction in blood levels of potassium with an increase in
sodium. Further to this Glycyrrhizinic acid directly has a weak binding effect on
mineralocorticoid receptors and will trigger the aldosterone loop via this mechanism also
to some extent. This has the net effect of driving an increase in blood pressure to result in
the hypertension often seen in excessive liquorice consumption. This is known as an
additive effect in pharmacology where 2 substances exert the same biological effect on
the body to result in what is essentially over dosage (Flaws, B, 2004, p.313)

FURTHER CAUTIONS & CONSIDERATIONS

 Post-surgery
 Male sexual dysfunction
 Antibiotics

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 It is also recommended that Gān Căo not be consumed 2 weeks pre or post-surgery due
to the potential issue of blood pressure regulation (RxList, 2016).
 Gān Căo should be cautioned in males experiencing sexual dysfunction due to
Glycyrrhizin and glycyrrhizinic acid having a weak agonistic effect on estrogen receptors.
 Due to the role intestinal flora play in the absorption of Glycyrrhizin by converting it to
the more readily absorbed Glycyrrhetic acid, consequently antibiotics may reduce
absorption. (Louis, Z, 2009)