Reactions to alcohol


IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor. The content of the information articles and all illustrations on this website remains the intellectual property of Dr Raymond Mullins and cannot be reproduced without written permission.

Allergic reactions to alcoholic beverages are uncommon, but have been described. By contrast, non-allergic adverse reactions to alcohol such as flushing, irritant reactions, toxic reactions and psychological effects are more common.

Alcohol 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 or due to naturally occurring substances such as amines in wood matured or brewed beverages.

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, should be verified with the manufacturer whether they still produce low sulfite beverages and no payment of any kind has been received by the author for this listing.

  1. BulletHapps (Margaret River, Western Australia) Tel 08-8562 2598

  2. BulletBotobolar (Mudgee, New South Wales) Tel 02-6373 3840

  3. BulletMacaw's Creek (Riverton, South Australia) Tel 08-8847 2237

  4. BulletHardy's "No added preservative wines" tel 1800 088 711

  5. BulletOrganic Wines Australia listings

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.

  1. BulletCoopers (Australia) Tel 08 8440 180

  2. BulletHolsten Premium Beer (from UK) Tel 02- 02 9722 1200

  3. BulletSelect Organics 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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Last reviewed April 2011