Episode transcript
Time stamps
0:00 Intro
2:29 Histamine Intolerance and Alcohol
4:27 Symptoms and Enzyme Deficiency
5:37 Sulfites and Asthma
8:02 ALDH2 Deficiency
9:14 Hidden Allergens in Alcohol
11:11 Alcohol as a Co-factor
15:02 Beer Allergens
19:24 Importance of Detailed History
20:49 Conclusion and Key Takeaways
Transcript:
Luke Lemons:
According to the World Health Organization, no amount of alcohol is safe for human health. However, 60% of U.S. adults still drink alcoholic beverages. And that's from a 2021 Gallup poll. But because of this prevalence, that's why we're talking about alcohol allergy today on ImmunoCAST and really all things alcohol and the way symptoms overlap.
Gary Falcetano:
Exactly. So stay tuned as we discuss alcohol allergy, intolerances, and even esophageal cancer.
Speaker 3:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP Specific IgE diagnostics, and Phadia Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed and board certified PA with over 12 years experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons, with over six years experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically-backed allergy insights. Welcome to ImmunoCAST. Gary, how are you holding up?
Gary Falcetano:
I'm doing okay, Luke. As you know, we've evacuated because of Hurricane Milton. I'm in a hotel room with my dog, my family, and lots of noisy neighbors, lots of other dogs who've evacuated. So if we have some background noise today, our listeners will know the source of that.
Luke Lemons:
I hope you're keeping safe out there. And with all those dogs, there's a pet allergen. There's got to be a hotel and pet allergy episode.
Gary Falcetano:
I'm thinking we need to be talking about pet allergy today, exactly. But unfortunately or fortunately, we are not. We're talking about alcohol allergy and adverse reactions to alcohol.
Luke Lemons:
And when it comes to alcohol allergy, it's a little odd because technically there is no such thing as an alcohol allergy because we can't make antibodies to small molecules like ethanol. They're just too small. A patient won't be allergic to ethanol. But when we say alcohol allergy throughout this episode, what we're relating to is the specific ingredients within these beverages. And we'll go more into that.
Gary Falcetano:
Exactly. And there's lots of intolerances, right? There's lots of reasons to experience adverse symptoms that patients may be presenting with that aren't true alcohol allergy. So let's sort all of that out.
Luke Lemons:
So why don't we start with what are the different adverse reactions associated with alcohol? You had mentioned intolerance, and I think it's important to say again, and we always say, allergy is mediated by IgE. Intolerances are not mediated by IgE. There's a lot of different things that can cause a reaction due to an intolerance. However, the symptoms are the same.
Gary Falcetano:
For sure. And I think probably the best place to start with intolerances is something that looks exactly or very similar to allergic-like symptoms. And that's histamine or histamine intolerance. We know that all alcohol contains some levels of histamine and some alcohols contain quite a bit more than others.
Luke Lemons:
And this histamine, first, going to the levels of histamine that is in different types of alcohol, let's look at wine and beer, for example. So in white wine we see up to 120 micrograms per liter of histamine. For beer, it's up to 305. For champagne, it's up to 670 micrograms per liter. And for red wine, it's actually up to 3,800 micrograms per liter of histamine that can be found in red wine.
Gary Falcetano:
Listening to these micrograms per liter, it's hard to actually put what is the impact on symptoms. But I think the massive difference between a maximum amount of histamine of 120 in white wine and a maximum amount of histamine of 3,800 micrograms per liter in red wine, that's huge. And that kind of explains why we hear so often people having issues specifically with red wine.
Luke Lemons:
As we've talked about before, histamine obviously released during an IgE-mediated reaction. This is why we have anti-histamines and things like that. So what we're talking about here is actually histamine being directly ingested. It's not due to an IgE-mediated reaction. But because it's still histamine, at the end of the day, the symptoms are very similar.
Gary Falcetano:
Yeah, exactly. I mean, just because it's not being released as a preformed mediator for mast cells doesn't mean it's going to have any different effects on the body.
Luke Lemons:
And so a patient who's reacting to red wine or really any beverage of alcohol, histamine is in all alcohol, they may have an allergy, they may not. It really goes into case history. But can you talk a little bit, Gary, on why someone might have this issue with histamine if they have an alcohol intolerance?
Gary Falcetano:
Before I do that, I think it's important, a lot of the symptoms that we see between allergy and intolerances are very similar. There's a lot of overlap. So we see flushing, itching, nasal congestion, GI issues, and then usually with allergy we see even more dramatic symptoms like hypotension, shortness of breath or tachycardia. Regardless, histamine can cause all of those, whether it's being released by our mast cells in a true IgE-mediated allergy fashion, or whether it's being ingested and processed by the body because of its high amounts in foods. Now, as you said, Luke, some people have a lot more issues with ingested histamine than others, and that really comes down to an enzyme. And we'll talk a lot about enzymes today. But in this case, we're talking about diamine oxidase. And diamine oxidase is what humans use to actually process histamine. And if we have a deficiency of that, we tend to be more sensitive to higher histamine or histamine containing foods.
Luke Lemons:
And it's not just histamines that may cause symptoms if the patient has an alcohol intolerance. There's also sulfites. And any person out there who loves their wine, probably hears a lot about sulfites. But sulfites also cause a non-IgE mediated release of histamine.
Gary Falcetano:
And we see varying amounts of sulfites in different alcoholic beverages and especially the wines. So we definitely know that certain wines contain more sulfites than others, and they tend to provoke these sulfite-induced histamine release and subsequent symptoms.
Luke Lemons:
There's something interesting about sulfites, right, Gary, in relation to asthma, actually?
Gary Falcetano:
Yeah. I mean, this is where we see probably the most sulfite reactions or symptoms are in patients with asthma, and especially those with poorly controlled asthma. It's really important to know that probably like, what, five to 10% of people with asthma are actually sensitive to sulfites.
Luke Lemons:
And this is why, you had mentioned poorly controlled asthma, it's important that patients are controlled with their asthma and part of that is knowing potential allergic triggers if they have asthma, just because if they are drinking alcohol and they also have a sulfite sensitivity, this may be a bad combination for those patients.
Gary Falcetano:
Exactly. It's just one more reason to be sure that our patients are well controlled. And that goes back to, as you said, not only assessing for and addressing triggers that they're sensitized and allergic to, but also just assessing their control at every visit, using an Asthma Control Test to uncover those patients who may not be presenting with obvious poor control but are actually poorly controlled.
Luke Lemons:
And so we have a histamine intolerance, we have a sulfite sensitivity, but there's also a ALDH2 deficiency, which is another type of alcohol intolerance your patients may have.
Gary Falcetano:
We mentioned this on previous episodes, but aldehyde dehydrogenase 2 deficiency, also known as Asian flush because it's very prevalent from a genetic standpoint in patients of East Asian descent. When patients have this deficiency, they're really unable to effectively metabolize ethanol. And we see a lot of symptoms that look allergy-like in these patients as well. This is facial flushing, tachycardia, nausea, headaches. And this is really a significant issue. We know that up to 40% of patients of East Asian descent and 8% actually of the entire world's population have this ALDH2 deficiency.
Luke Lemons:
Let's take a little sidebar here, but an interesting fact, this isn't necessarily related to allergy, but something that I think providers should know, is that ALDH2 deficiency is also associated with a significantly higher risk of esophageal cancer.
Gary Falcetano:
So I mean, significantly elevated. You would think, okay, if a patient has this deficiency and they're having this flushing response, they would avoid alcohol. But that's not always the case. Some people push through it, but other people develop a tolerance to it, and their flushing response actually decreases over time, so they continue to ingest alcohol. And these people are at really high risk of developing esophageal cancer. So it's super important for clinicians out there to be aware of this and to really screen for this, especially in their patients of Asian descent, because they can be at such high risk for esophageal cancer. And it's a very deadly cancer, as we know.
Luke Lemons:
And during a physical, when a patient comes in, that's one of the most common questions is how many alcoholic beverages do you have per week, would you say? That uncovers so much. You had just mentioned cancer here, understanding if they might have an alcohol intolerance, but then also trying to differentiate allergy from also these reactions as well in potential disease states. And so why don't we pivot now to alcohol allergy, which is the allergy to the substance inside alcohol. But it's kind of difficult for patients to understand what they're allergic to or what they may be exposed to in alcohol, right, Gary?
Gary Falcetano:
It really becomes a game of uncovering hidden allergens.
Luke Lemons:
Truly hidden.
Gary Falcetano:
So we know that the Federal Alcohol Administration Act, or the FAA Act, doesn't require alcoholic beverages to be labeled with potential allergens. It's one of the few things that we ingest that falls outside of the regulation of the FDA.
Luke Lemons:
And it's not just allergens, it's all ingredients really, unless they're making a health claim. But we talked about hidden allergens in foods, but these are truly hidden allergens. You can't pick up a can of beer and see what potential allergens might be in there. That's at a huge risk for patients. It's important to understand and try to uncover. Is it an intolerance or is it an allergy? Another interesting fact, and Gary, maybe you can expand on this, is when it comes to serum IgE levels, they're higher in alcoholics and moderate drinkers.
Gary Falcetano:
We've definitely seen research that, especially patients that are moderate to even heavy drinkers, have considerably higher total IgE levels. And sometimes that's associated with specific IgE sensitizations and allergy, and sometimes it's not, but it's been postulated that regular alcohol consumption can actually increase sensitization to other allergens. So back when we talked about the reasons why people become allergic, and we talked about the epithelial barrier hypothesis, it may be that alcohol helps antigens or potential allergens migrate this epithelial barrier more efficiently without being broken down, causing the body to initiate a Th2 response and sensitization.
Luke Lemons:
And we have an episode on a little more about the epithelial barrier hypothesis, and that's our climate change episode. We'll link to that on this episode's page on our website and also in the description here. But there's also another way that the epithelial barrier hypothesis ties in when we talk about alcohol and it's really alcohol as a cofactor.
Gary Falcetano:
Yeah, and we've mentioned cofactors and the role that they play in someone exhibiting symptoms to something that they're already been sensitized and allergic to in the fact that they may not exhibit symptoms if the cofactor isn't present. And alcohol is certainly a major cofactor when it comes to this. And if you remember back to our alpha-gal syndrome episode, we've seen multiple case studies where patients only reacted to red meats or ingestion of red meats if they were concomitantly consuming alcohol. So having a glass of red wine with their steak.
Luke Lemons:
And so alpha-gal syndrome, also known as red meat allergy, this combination is very dangerous to a patient who has that syndrome because they're eating red meat, the steak, and now they're drinking alcohol. And because the alcohol is making the epithelial barrier a little more permeable, they're at a higher risk of having a reaction.
Gary Falcetano:
Exactly. It's just increasing the permeability. So it's increasing the uptake of the red meat proteins, the alpha-gal itself in the red meat, into the systemic circulation.
Luke Lemons:
So why don't we go into more specifically the different types of alcoholic beverages. Mainly let's look at beer and wine first and start with wine. We had mentioned that wine has a lot of histamine in it. However, what about potential allergens?
Gary Falcetano:
With wine, the first place we go is the grape, right? And we can certainly have grape allergy, and that's related to multiple proteins. In previous episodes, we've talked about the allergen component that make up the whole allergen. And we know that in grape allergy, we often see allergic symptoms related to lipid transfer proteins or the LTPs in grapes. And remember, these are found in a lot of different plants and plant foods, and there's even something called LTP syndrome where someone will have allergy to multiple LTP-containing foods.
Luke Lemons:
More interestingly, but when it comes to wine, it's a little more interesting, the assumption would be, like, "Oh, the only allergen in wine is grapes."
Gary Falcetano:
Not so much.
Luke Lemons:
May not. So during the fining process of wine, which is removing impurities or small molecules, this is different from filtering, which is taking out sediment, but during the fining of wines, there is a slew of potential allergens that are added.
Gary Falcetano:
And the wine actually comes in contact with these. Some they say don't really remain in the wine, but with some of these, traces can remain in the finished product.
Luke Lemons:
Yeah, I mean, on a chocolate bar, we have to say if it's made near peanuts or in the same factory as peanuts, and you know in this instance it's being poured directly into the wine and be mixed in.
Gary Falcetano:
Some of these allergens I would've never thought of. So there's fish gelatin, and the other name for that is isinglass, which is the swim bladder of a Huso fish, which is in the family of sturgeons. There's ovalbumin from eggs. There's casein from milk. There's a lot of ingredients that are used in wine production I would've never thought of.
Luke Lemons:
Discovering that just made me, just imagining the fish gelatin being added to your nice glass of red wine. But again, the FAA Act does not say that alcohol has to put potential allergens on the label of alcohol. And especially you didn't mention the molds and the yeasts that are used in the production of wine.
Gary Falcetano:
For sure. And we know patients with mold allergies can certainly have symptoms when exposed to them in wines.
Luke Lemons:
Again, because of the FAA Act, they don't have to put potential allergens that are found within or have come in contact with the alcohol. And so a patient may be reacting to wine, and it may be because of the high histamine levels in it. It may be if they have a low threshold for these allergens that we've just mentioned that they're reacting to that as well, or instead of.
Gary Falcetano:
Yeah, for sure. But it's not just wine. So why don't we move on to another highly consumed beverage? What about beer?
Luke Lemons:
Beer, yes. So again, we think wheat, barley, hops, corn, all of these things are potential allergens that may cause a patient to react. And again, you had mentioned with grape allergy, there is lipid transfer proteins here as well, LTPs.
Gary Falcetano:
For sure. And there are new diagnostic tests that can really help sort out some of these LTP sensitizations and allergies. Specifically, there's a wheat allergen component called Tri a 14, which is the lipid transfer protein in wheat that can kind of help with this as well.
Luke Lemons:
Can you talk a little bit about the wheat component?
Gary Falcetano:
When we talk about wheat allergy, it can be a difficult allergy to diagnose, right? Because wheat is in the grass family and people that are allergic to grasses may show sensitization to wheat but not be clinically allergic. Certainly if you're reacting to the wheat that's in beer, you are clinically allergic. And one of the ways that we can help diagnose wheat allergy itself is through the wheat allergen components because they allow us to take a positivity of a whole allergen wheat and really be more specific with it. So whether it be the LTP, the lipid transfer protein Tri a 14, whether it be one of the omega or the other gliadens like the omega-5 gliadin Tri a 19, these all help to make the wheat diagnostic more specific and help diagnose wheat allergy.
Luke Lemons:
So it helps in understanding whether it's truly a wheat allergy or if it's this LTP syndrome that you've talked about.
Gary Falcetano:
Correct. But Luke, trying to be a little healthier, trying not to have as much alcohol in my diet, but still like the taste of a beer now and then. What about non-alcoholic beers?
Luke Lemons:
So non-alcoholic beers, while they still may have small or trace amounts of histamine, they still can contain allergens. And also, even though they're not alcoholic, they still don't have to declare the allergens that may potentially be within them or if they were made alongside other potential allergens.
Gary Falcetano:
So those aren't regulated by the FDA either. They're regulated under the Federal Alcohol Act.
Luke Lemons:
Yeah. And it's also worth noting that just because it says non-alcoholic, there're non-alcoholic beers that have 0.5% or less alcohol in it, that is the threshold that they classify an alcoholic beverage versus a non-alcoholic. And that's why there's traces amount of histamine in it, because there's histamine in all alcohol, and there is still maybe a little bit of alcohol in those non-alcoholic beers.
Gary Falcetano:
The bottom line when it comes to really uncovering potential allergens in alcoholic beverages, whether it be beer or wine, really comes down to doing some good investigations and really trying to figure out what may be in what the patient ingested. But what about spirits? Are we home free with that or no?
Luke Lemons:
In my opinion, I think that this is the biggest risk to patients. If a patient is reacting to a spirit, it could be a lot of different things because unless they're just shooting shots of whiskey, spirits are found in a lot of cocktails, and there's a lot of different allergens that are found in these cocktails.
Gary Falcetano:
And I've actually seen even pure whiskey, Luke, when it's aged in wooden barrels, there's allergens that are transferred from the wood. So even pure whiskey can contain allergens. But as you said, there's a lot of added allergens, especially in specialty cocktails and spirits, whether it be hazelnuts in Frangelico, the milk in some cream liqueurs. We really have to take a pretty in-depth analysis to figure out what patients may have been potentially exposed to.
Luke Lemons:
And not to mention egg white used in a lot of cocktails as well. And so a patient may come in and say, "Well, I'm reacting to alcohol. I think I have an alcohol intolerance or an alcohol allergy." The first thing you should probably figure out is what are they drinking? Because if their go-to is just an old [inaudible 00:19:00] the whole time, that tells us a little more about what may be causing this reaction.
Gary Falcetano:
It all comes down to, and we've said this multiple times, it really comes down to doing a very thorough history. What were all the circumstances around the potential reaction, all of the potential allergens ingested, as well as the circumstances involved. And putting that all together can really be a bit challenging.
Luke Lemons:
To that point, alcohol is one of the most widely consumed substances in the world, and so many patients are drinking. And so understanding how they drink and the case history behind why they may be reacting is important. But another half of helping to uncover what may be causing reaction is Specific IgE blood testing for potential allergens. We had been saying this whole episode, there's a lot of symptom overlap here.
Gary Falcetano:
Yeah, for sure. So basing any Specific IgE testing on that history to be sure that we're really doing a targeted analysis of their potential triggers and then looking at the whole picture. So one of the most surprising things that I recently became aware of was that link with esophageal cancer and patients with the ALDH2 deficiency. So really, Luke, the take home here is while we know that alcohol consumption itself is not generally considered completely without risks, there's no safe level of alcohol consumption, there are certainly a lot of increased risks for certain patient groups and figuring that out among our potentially allergic patients, our patients with potential enzyme deficiencies like the ALDH2 deficiencies, and the link to increased risks of esophageal cancer, I think it's very important to be aware of all these things so we can really help our patients who continue to consume alcohol really be as healthy as possible.
Luke Lemons:
Yeah, I 100% agree. And let's not forget too about sulfites and the link to asthma patients as well. So again, we've said, I think, three times now in a row almost, but it's detailed history. And then using diagnostics like Specific IgE blood testing to help uncover or rule in or rule out the risk of allergens. Because if you find out that a patient has an allergy due to you investigating reactions to alcohol, that changes a lot of aspects in a patient's life, that cascades across. And it's always important to know. Knowledge is power.
Gary Falcetano:
Knowledge is power and these allergens can be found in multiple sources outside of alcoholic beverages.
Luke Lemons:
And testing is accessible to all types of provider when it comes to Specific IgE blood testing. It's very accessible to all types of providers. And on this episode specific page, we'll have a link to the lab ordering guide that we always shout out that has test codes for all different types of labs in your area based on your zip code that you probably already use. So check that out. And again, thank you for listening to ImmunoCAST. Gary, I hope that you're staying safe right now.
Gary Falcetano:
Absolutely. I'm going to do my best, Luke, and I want to thank everyone out there for listening, and we'll see you next time.
Luke Lemons:
Thanks.
Speaker 3:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP™ Specific IgE diagnostics and Phadia Laboratory Systems. For more information on allergies and Specific IgE testing, please visit thermofisher.com/immunocast. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside Specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis, or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
