Are Passiflora incarnata (passion flower) and L‑theanine safe to use in a patient with liver cirrhosis?

Safety of Passion Flower and L-Theanine in Cirrhosis

Passion flower should be avoided in patients with cirrhosis due to documented hepatotoxicity and lack of safety data, while L-theanine appears relatively safe but requires caution in decompensated disease.

Passion Flower (Passiflora incarnata) – Not Recommended

Evidence of Hepatotoxicity

• Fatal hepatic failure has been reported with passion flower-containing preparations, including a documented case of acute liver failure and death in a patient using a kava-passion flower combination 1.
• The patient died despite warnings from regulatory authorities about hepatotoxicity risk, highlighting the serious potential for liver injury 1.

Cardiovascular and CNS Concerns

• Passion flower has caused severe adverse effects including prolonged QTc interval, nonsustained ventricular tachycardia, nausea, vomiting, and drowsiness at therapeutic doses, requiring hospital admission for cardiac monitoring 2.
• These cardiovascular effects are particularly concerning in cirrhotic patients who may already have circulatory dysfunction and QT prolongation.

Drug Interactions

• Passion flower demonstrates additive or synergistic effects with benzodiazepines and other CNS depressants by increasing GABA receptor activity, causing severe secondary effects including handshaking, dizziness, throbbing, and muscular fatigue 3.
• Cirrhotic patients are already at high risk for hepatic encephalopathy and CNS depression, making these interactions especially dangerous.

Perioperative Guidelines Perspective

• The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends continuing passion flower in surgical patients specifically because it may provide anxiolytic benefit 4.
• However, this recommendation applies to patients without liver disease undergoing elective surgery, not to patients with established cirrhosis 4.

Clinical Bottom Line for Passion Flower

• The documented hepatotoxicity, cardiovascular toxicity, and CNS interactions outweigh any potential anxiolytic benefit in cirrhotic patients.
• Alternative anxiolytics with established safety profiles in liver disease should be used instead.

L-Theanine – Use with Caution

Pharmacologic Profile

• L-theanine is a glutamate derivative with dose-dependent blood pressure lowering effects 4.
• It undergoes rapid metabolism with a short elimination half-life, allowing for a 24-hour hold period before procedures 4.

Safety Considerations in Cirrhosis

• No specific hepatotoxicity has been documented with L-theanine in the available literature.
• The rapid metabolism suggests lower risk of accumulation compared to drugs requiring extensive hepatic processing.

Hemodynamic Concerns

• The dose-dependent hypotensive effect is relevant in cirrhotic patients who may have baseline hypotension, especially those with:
  • Refractory ascites
  • Hepatorenal syndrome risk
  • Patients on non-selective beta-blockers (which should be monitored closely if mean arterial pressure <65 mmHg) 5

Practical Recommendations for L-Theanine

• May be used cautiously in compensated cirrhosis (Child-Pugh A) with blood pressure monitoring.
• Exercise greater caution in Child-Pugh B or C due to:
  • Baseline circulatory dysfunction
  • Risk of precipitating hepatorenal syndrome with hypotension 5
  • Potential for worsening hepatic encephalopathy with any CNS-active agent

Alternative Anxiolytic Approaches in Cirrhosis

Medications to Absolutely Avoid

• NSAIDs are absolutely contraindicated in all cirrhotic patients as they impair renal sodium excretion, precipitate renal dysfunction, and convert diuretic-responsive ascites to refractory ascites 4, 5.
• Benzodiazepines are contraindicated in decompensated cirrhosis and should be discontinued immediately if hepatic encephalopathy develops 4, 5.

Safer Alternatives

• Address underlying precipitants of anxiety including hepatic encephalopathy, infection, electrolyte disturbances, and gastrointestinal bleeding 4, 5.
• Optimize treatment of the underlying liver disease (alcohol cessation, antiviral therapy, immunosuppression) as this is the most important intervention to prevent further decompensation 5.
• Consider non-pharmacologic interventions including cognitive-behavioral therapy and relaxation techniques.

Monitoring Requirements if L-Theanine is Used

• Check blood pressure regularly, especially in patients on diuretics or beta-blockers.
• Monitor for signs of hepatic encephalopathy (altered mental status, asterixis, changes in Animal Naming Test performance) 4, 5.
• Assess renal function (serum creatinine, sodium, potassium) at least weekly if starting any new agent in a patient on diuretics 4, 5.
• Watch for drug interactions with other CNS-active medications.

Common Pitfalls to Avoid

• Do not assume "natural" products are safe in liver disease—passion flower demonstrates clear hepatotoxicity 1.
• Do not ignore cardiovascular effects—passion flower's QTc prolongation and ventricular arrhythmias are serious concerns 2.
• Do not combine with benzodiazepines or other CNS depressants if using either supplement, as synergistic toxicity is documented 3.
• Do not use any supplement without considering the Child-Pugh class—decompensated cirrhosis (Child-Pugh B or C) has fundamentally different pharmacokinetics and tolerance 4.