Ps-r07-1: case of pseudohyperaldosteronism with improvement of hypertension and hypokalemic weakness by discontinuation of peony and licorice formula.

Case: An 80-year-old woman was admitted to our hospital with lower extremity weakness. She was treated for hypertension (HT), type 2 diabetes, and Alzheimer's disease. Her medications included brotizolam 0.25 mg, rivastigmine tape 18 mg, celecoxib 200 mg, sofarcon 50 mg, losartan 50 mg, hydrochlorothiazide 12.5 mg, rosuvastatin 2.5 mg, propiverine 10 mg, empagliflozin 10 mg, linagliptin 5 mg, esomeprazole 20 mg, peony and licorice formula (PLF) 7.5 grams, and olopatadine 5 mg. On admission her blood pressure (BP) was 191/73 mmHg. Manual muscles testing (MMT) for the upper limbs was 4/5 bilaterally throughout. Lower limb MMT included iliopsoas 1/5, quadriceps 1/5, hamstrings 1/5, anterior tibialis 4/5, gastrocnemius 4/5 bilaterally, respectively. Basic blood tests revealed serum K + 2.0 mEq/L, urinary K + 21.0 mEq/L, creatinine kinase 1,488 U/L, renin activity 0.8 ng/mL/hr, and aldosterone 4.0 pg/mL (CLEIA method). During admission to the intensive care unit, frequent blood sampling was performed to correct the serum K + level. A calcium channel blocker (CCB) was commenced for HT on admission day. Spironolactone was commenced on post-admission day (PAD) 1. The serum K+ level stabilized, and potassium chloride administration was terminated PAD 6. BP also improved over time, and the CCB was discontinued on PAD 23. On the same day, she was discharged from the hospital with continuation of spironolactone. In this case, there were a total of 11 prescription drugs including PLF from three clinics. We diagnosed HT and lower extremity weakness due to pseudohyperaldosteronism (PHA). The HT improved after discontinuation of PLF. Licorice is found in about 70% of Chinese herbal medicines. Risk factors for PHA include short stature and weight, elderly and female, renal dysfunction, and diuretic administration. As Japan has entered a super-aging society, the number of patients using geriatric healthcare facilities and chronic care wards is increasing. The frequency of blood sampling is particularly low in such facilities, so it is difficult to notice hypokalemia among such patients. PHA and hypokalemic myopathy due to licorice should be considered in the case of lower limb weakness in elderly patients. In conclusion, it is important to identify PHA caused by licorice-containing Chinese herbal medicines in elderly patients with HT. In addition, healthcare facilities for the elderly it is advised that serum K+ is checked in patients with worsening HT, weakness and polypharmacy.