Adverse
and allergic reactions to alcoholAlcohol is a natural product
Alcohol (ethanol) is a normal by-product
of human and animal cell chemistry/metabolism. Cell processes
result in normal physiological levels of 0.01 to 0.03 mg of alcohol/100
ml of blood. By contrast, a blood alcohol limit for driving of
0.05 per cent is equivalent to 50 mg of alcohol/100 ml of blood.
Alcohol is broken down in the liver
Alcohol (ethanol) is broken down by
liver enzymes within minutes. Conversion of ethanol to acetaldehyde
requires the enzyme alcohol dehydrogenase. Acetaldehyde
is then transformed to acetic acid ("vinegar") by the
enzyme aldehyde dehydrogenase. If individuals can't break
down alcohol easily, problems may occur if alcohol is consumed.
Flushing is not an allergic reaction
Some patients will experience intense
facial flushing after having even small amounts of alcohol. These
symptoms are most common in those with an oriental / Asian background.
Other side-effects of fluttering of the heart (palpitations, tachycardia),
sensation of heat, headache, tummy discomfort or a drop in blood
pressure (hypotension) are related to high blood acetaldehyde
levels. Individuals with these problems appear to be partially
deficient in aldehyde dehydrogenase, resulting in high
levels of accumulated acetaldehyde.
Other conditions may also trigger flushing
Not all flushing is due to alcohol.
Flushing can occur in skin conditions such as rosacea, the menopause,
low blood sugar levels (hypoglycaemia), and sometimes as a response
to some antibiotics or medicines used to treat diabetes or high
blood fat levels.
Alcoholic
beverages contain ethanol and other substances
The liver breaks down the alcohol (ethanol)
we drink and converts it to a chemical called acetaldehyde. Acetaldehyde
is then transformed to acetic acid ("vinegar"). Problems
occur if alcohol cannot be broken down. As well as ethanol, alcoholic
beverages contain a complex mixture of grape, yeast, hop, barley
or wheat-derived substances, natural food chemicals (eg. salicylates),
wood and fruit-derived substances (eg. Histamine, tyramine in
chianti), added enzymes (like papain) and preservatives (like
sulphites). Severe allergic reactions have been described in people
with allergies to proteins within grapes, yeast, hops, barley
and wheat. These patients are not sensitive to alcohol itself.
Furthermore, "fining agents" (like egg protein, milk
proteins, parvalbumin and seafood proteins and "isinglass"
which is a fish swim-bladder product) are sometimes used to remove
fine particles. Whether these occur in sufficient amounts to trigger
allergic reactions is unknown.
Asthma can be triggered by sulphites
(sulfites)
Up to a third of people with asthma complain that
wine will worsen their asthma, less often with beer or spirits.
Beer, wine and champagne contain sulphites (additive 220-226),
used as a preservative since Roman times. Some people, particularly
those with unstable or poorly controlled asthma, may wheeze when
they consume these drinks. In general, there is more preservative
in white wine than red wine, and more in cask wine than bottled
wine. The amount of metabisulphite also varies from brand to brand.
Some "low sulphite" wines are available, although those
with extreme sensitivity may not be able to tolerate them. This
is because some grape growers will dust sulphur powder over grapes
in the weeks leading up to harvest. Other sources of sulphites
include vinegar, pickled onions, dried fruit, or when dusted onto
crustaceans and some restaurant salads or fruit salads. Sometimes
grapes are transported with bags of sulphites to keep them fresh.
Even when people complain that wine triggers asthma, sulphites
may not be the only explanation.
Low /no sulfite wines
As a rule, sulfites are found at higher levels in the cask
wine than bottled wine, and are at much higher concentrations
in white wine than red wine, when natural tannins help preserve
the beverage. Some winemakers in Australia produce wines and state
that they do not add sulfites into the wine. There are various
technical reasons related to winemaking why very low levels of
sulfites might still be present, even when not added to the wine
itself. The author has not personally verified the claims of being
preservative free. Those interested should make inquiries of the
winemaker. The following Australian winemakers produce low / no
sulfite wines. This listing is for information purposes only,
is not exhaustive, should not be interpreted as a recommendation,
and no payment of any kind has been received by the author for
this listing.
Low / no sulfite beers
Some brewers produce beer and state that they do not add sulfites.
There are various technical reasons why very low levels of sulfites
might still be present, even when not added to the product itself.
The author has not personally verified the claims of being preservative
free. Those interested should make inquiries of the brewery. The
following brewers claim to produce low / no sulfite beers. This
listing is for information purposes only, is not exhaustive, should
not be interpreted as a recommendation, and no payment of any
kind has been received by the author for this listing.
Asthma can also be due to enzyme deficiency
Patients with aldehyde dehydrogenase
deficiency accumulate high levels of acetaldehyde after consuming
alcohol. Acetaldehyde has been blamed for asthmatic reactions
to alcohol in up to half of Japanese asthma patients. Sometimes
histamine within alcoholic beverages has been blamed for allergic
reactions.
Histamine and other substances may also
cause problems
Histamine can trigger sneezing, runny nose and sometimes wheeze,
stomach upset and headache. There is more histamine in red than
white wines, although the amounts will vary from wine to wine.
Some small studies have shown that antihistamines can help reduce
the severity of symptoms, but as the amount of wine challenge
was equivalent to only one glass, probably won't prevent hangovers!
Others substances within wine may also cause problems to some
unlucky individuals, but these are not well defined.
Serious allergic reactions to beer or wine
may occur
Anaphylaxis has been described in patients
with severe allergic reactions to proteins within grapes, yeast,
hops, barley and wheat. These patients are not sensitive
to alcohol itself.
Anaphylaxis to alcohol is rare
Allergic reactions to alcohol itself
are rare, but described in a few dozen published case reports.
As little as 1 ml of pure alcohol (equivalent to 10ml of wine
or a mouthful of beer) is enough to provoke severe rashes, difficulty
breathing, stomach cramps or collapse, a condition known as anaphylaxis.
Given that the body constantly produces small amounts of alcohol
itself, the reason that such reactions occur is poorly understood.
Allergy tests using alcohol are usually negative, but sometimes
positive to breakdown products of ethanol such as acetaldehyde
or acetic acid ("vinegar"). Provocation tests with alcohol
are usually positive, but only sometimes when acetaldehyde or
acetic acid are used. Finally, alcohol can sometimes act as a
"co-factor", increasing the likelihood of anaphylaxis
from other causes.
Sources of alcohol are not always obvious
When one thinks of alcohol sensitivity,
beverages come immediately to mind. There are however, potentially
a number of other less obvious sources. These include as alcoholic
soft drinks, mixes, spiked drinks, food marinades or tomato puree.
Over-ripe fruit can ferment, resulting in enough alcohol production
to trigger a reaction. Some medicines like cough syrups also contain
alcohol, as do some medicines given by injection.
Management of alcohol allergy
Accidental exposure may lead to unexpected
reactions. Patients with alcohol allergy should be managed in
the same way as others with serious allergic reactions: identify
and avoid the cause, wear a Medic Alert bracelet, and carry adrenaline
(epinephrine) as part of an emergency action plan if they are
at risk of dangerous allergic reactions in the future.
Milder reactions to alcohol may also occur
Alcohol can worsen symptoms in patients
with hives / urticaria. Occasionally, alcohol can also trigger
hives directly. As with more serious allergic reactions, the mechanism
is unclear. Less common reactions include localized contact hives
and contact dermatitis.
Not all adverse reactions to alcohol are
due to allergy
Other effects of alcohol toxicity are
well known, including its effect on the liver, stomach, brain
and mental functioning in large amounts. Even though alcohol has
a relaxant effect on the brain, some individuals will experience
paradoxical agitation and anxiety. Such symptoms are due to the
drug-like activity of alcohol. They do not represent "allergy"
anymore than a "hangover" does.
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