Q:

10/12/2013
I have seen at least 20 patients with delayed anaphylaxis due to alpha gal at my location since opening clinic 5 months ago! Wow, what a difference from my last location where I saw this type of a case two times in 18 years.

I have questions about which foods contain alpha gal besides mammalian red meat. I have found bovine gelatin, and cow's milk listed. My patients are asking about almond milk - is this safe? Any other foods they need to avoid?

Is there any article about the levels of alpha gal in various foods and the relative risk of ingesting these foods, specifically drinking cow's milk in pts with positive alpha gal?

This is a great quandary for me, because an ingestion challenge is not practical due to the delay in systemic reaction from ingestion time.

A:

Thank you for your inquiry.

As you know, Dr. Scott Commins is an internationally known expert in this disorder, and he, along with Dr. Tom Platts-Mills, have contributed the bulk of the literature regarding alpha-gal reactions. I am therefore sending your inquiry to Dr. Commins. As soon as we hear from him, we will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We have received a response from Dr. Scott Commins. Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Scott Commins:
Certainly this is a great question and one of utmost practical importance to patients. In general, most patients who develop IgE to alpha-gal are able to tolerate cow's milk without difficulty. In fact, I do not routinely restrict dairy for a patient unless they report symptoms that could be attributed to milk, cheese, etc. There are other patients, however, who report symptoms despite compliance with a mammalian meat avoidance diet. In these patients with "lingering" symptoms, I will frequently suggest removal of further mammalian products such as cow's milk, cheese, ice cream, etc. While we have had patients report distinct allergic symptoms (itching, hives) after consuming dairy, this has been the exception. When patients have reported issues with dairy-related foods, it has typically been items of higher fat (creams, rich cheeses, etc). We have investigated alpha-gal levels in a few foods and other mammalian tissues (published in Mullins et al, JACI 2012):

By using similar techniques, the concentrations of alpha-gal were 5.6 μg of alpha-gal per gram of beef thyroglobulin and 1.4 μg of alpha-gal per gram of heavy cream. By contrast, no detectable alpha-gal was found in cow's milk (skim or 1% or 2% milk fat). Of the 21 oligosaccharides identified on cetuximab, approximately 30% have 1 or more alpha-1,3-linked galactosyl residues, as measured by peak area on time-of-flight mass spectrometric spectra, and alpha-gal was detected at a concentration of 10.2 μg/5 mg of cetuximab.

Given its plant origin, almond milk would be safe for patients allergic to alpha-gal who did not have concomitant IgE to almond. In a few patients with IgE to alpha-gal, gelatin has been an issue but this also appears to be quite uncommon and I do not routinely advise avoidance other than mammalian meat.
 
Scott Commins, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology