What is the management plan for an alpha-gal allergy?

Management of Alpha-Gal Syndrome

The management of Alpha-Gal Syndrome (AGS) primarily involves complete avoidance of all mammalian meat products and mammalian-derived products, with safe alternatives including fish, seafood, poultry, and plant-based foods. 1

Diagnosis Confirmation

• Diagnosis should be confirmed with:
  • Serum testing for alpha-gal IgE antibodies (positive result >0.1 IU/mL)
  • Clinical correlation with symptoms (delayed reactions 3-6 hours after mammalian product consumption)
  • Improvement of symptoms after adherence to an alpha-gal avoidance diet 1

Management Protocol

Dietary Restrictions

• Complete avoidance of all mammalian meat products including:
  • Beef, pork, lamb, venison, rabbit, and other red meats
  • Mammalian organ meats
  • Products containing mammalian-derived ingredients
• Caution with dairy products (typically cause milder reactions but may still affect sensitive individuals) 1
• Safe food alternatives:
  • Fish and seafood
  • Poultry (chicken, turkey)
  • Plant-based foods 1

Medication Management

• Prescribe epinephrine auto-injector for patients with history of systemic reactions 1
• Recommend antihistamines for management of milder reactions 1
• Avoid medications containing alpha-gal such as:
  • Cetuximab
  • Infliximab
  • Some medications with mammalian-derived ingredients 1, 2

Tick Bite Prevention

• Essential to prevent worsening of the allergy:
  • Regular tick checks after outdoor activities
  • Showering promptly after potential tick exposure
  • Treating clothing with permethrin
  • Creating barriers at ankles by pulling up tight mesh socks over pant cuffs
  • Using EPA-approved insect repellents
  • Avoiding tick-infested areas when possible 2, 1

Follow-Up and Monitoring

• Repeat alpha-gal IgE levels 6-12 months after diagnosis if tick bites are avoided 2, 1
• Monitor for symptom improvement after dietary elimination
• As IgE levels decrease or become negative, patients may be able to gradually reintroduce:
  1. First, small amounts of low-fat dairy products
  2. Then, lean mammalian meat in small portions 2

Important Considerations

• Reactions can be inconsistent - patients may tolerate red meat occasionally but still have AGS 2
• Co-factors that increase reaction risk and severity:
  • Fattier cuts of meat
  • Nonsteroidal anti-inflammatory drugs
  • Exercise
  • Alcohol consumption 2
• Reintroduction protocol:
  • Only attempt with decreasing alpha-gal IgE levels and no recent tick bites
  • Start with quarter serving of meat
  • Have antihistamines and epinephrine available
  • Have another person present to monitor for symptoms
  • Work with an allergist for patients with history of significant systemic symptoms 2, 1

When to Refer to an Allergist

Refer patients to an allergist when they report:

• Skin or systemic changes
• Swelling of face or throat
• Voice changes
• Difficulty breathing
• Hives
• Fainting with reactions 2

Emerging Treatment Options

While avoidance remains the primary management strategy, limited evidence suggests potential future treatments:

• Oral immunotherapy has shown promise in small studies but is not yet standard practice 3
• No established desensitization protocols are currently recommended by major guidelines 2

Alpha-gal syndrome is often underdiagnosed due to limited awareness among healthcare providers, with 42% of surveyed providers having never heard of AGS 4. Therefore, increased education and awareness are essential components of improving patient care.