Removing Trace Amounts of Alpha-gal from Your Diet

A Guide for People Highly Sensitive to Alpha-gal

Don’t skip steps

Before you jump into the information on this page, read Determining Your Tolerance to Alpha-gal Parts I and II (see below). Most people with alpha-gal syndrome (AGS) tolerate exposure to small amounts of alpha-gal, and these steps may be enough. We recommend you work through the steps in order, rather than prematurely limiting your food choices and possibly adding to your food bills.

• This information is for people who have completed Part I of Determining Your Tolerance to Alpha-gal and are still reacting.
• If you are still eating mammalian meat or meat products, dairy, gelatin, or carrageenan, you have not completed Part I.
• Use the outline below as a guide, not a set of rules.
• Own the process, don’t let it own you. Nobody can follow these guidelines exactly all the time. It’s okay. Do what you have to do.

Familiarize yourself with these resources

• Food: First Steps, a Guide for People with Alpha-gal Syndrome
• Cross-contamination: A Guide for People with Alpha-gal Syndrome
• Gelatin: A Guide for People with Alpha-gal Syndrome
• Carrageenan: A Guide for People with Alpha-gal Syndrome
• Go Dairy Free
  • Remember that Go Dairy Free is for all people who want to avoid dairy, not people with alpha-gal syndrome.
  • Many dairy-free products contain ingredients, like carrageenan and gelatin, that contain alpha-gal.

Join a support group

Members of these Facebook support groups can help answer your questions and guide you through this process.

Seek a physician’s advice

Seek your physician’s advice before trying this approach.

• See a list of physicians with expertise in alpha-gal syndrome (AGS) here.
• See a more extensive list of physicians recommended by people with AGS here.

Mammalian byproducts

In Determining Your Tolerance: Part 1, we focus on how to eliminate meat, meat products, dairy, gelatin, and carrageenan from your diet. Here we concentrate on trace amounts of alpha-gal in mammalian byproducts in food.

• Hundreds of different mammalian byproducts are added to foods, medications, personal care, household, and even industrial products.
• These byproducts often have strange names, like monoglycerides and L-cysteine.
• It’s impossible to memorize all the names of the different mammalian byproducts. 
• Mammalian byproducts are ubiquitous. They turn up surprising places where you would least expect them. 
• When mammalian byproducts are used as processing agents, they are not listed as ingredients.
  • For example, gelatin is often used to clarify wine, but you won’t find it listed on the label, even though traces of it may remain in the final product.
• We don’t know how much alpha-gal different mammalian byproducts contain.
  • Severe reactions to some mammalian byproducts in people with AGS have been documented.
  • Some mammalian byproducts may not be glycosylated with alpha-gal at all.
  • Even byproducts that are not glycosylated with alpha-gal may be contaminated by molecules that are.
  • In the absence of more information, people highly sensitive to alpha-gal tend to avoid all mammalian byproducts.
• Find more information about mammalian byproducts here.
• The Alpha-gal Information Mammalian Byproducts Database is a searchable database that you can use to look up ingredients.
  • No complete list of all mammalian byproducts exists. Believe me, we looked and called every agency and association we could think of!
  • This AGI database is not complete, but as far as we know, it is the most comprehensive compilation of mammalian byproducts in existence.

The most problematic byproducts

It’s impossible to list all the ingredients that anyone with alpha-gal syndrome has reacted to. However, here are a few of the worst offenders:

• Lard/tallow/suet
• Collagen/gelatin
• Carrageenan
• Whey and other dairy byproducts
• Vitamin D3 (unless vegan it is usually made from lanolin)
• Glycerin (when derived mammals–some is plant-based)
• Mono- and diglycerides (when derived from mammals)

Check out Darcie Clements’ tips for deep cleaning your kitchen in her Alpha-gal Syndrome blogspot. She suggests paying particular attention to:

• Kitchenware with visible “ghosts” or residues
• Wooden and heavily scratched cooking equipment
• Cast iron pans, which need to be stripped and re-seasoned
• Grills
• Ovens
• Keep in mind that fat residue in pans, ovens, and grills previously used to cook mammalian meat may become aerosolized when heated, and the aerosols may be deposited on your food.
  • Unlike proteins, Alpha-gal is heat stable and not broken down by normal cooking temperatures.

Tips for deep cleaning your kitchen:

• Use vegan cleaning supplies, when possible. Popular vegan cleaning products brands include:
  • Seventh Generation
  • Mrs. Meyer’s
  • Find more brands here.
• Clean as a whistle–get your oven sparkling by VeganLife

While you figure out what you can and cannot eat, you are better off buying raw, unprocessed, additive-free food (like poultry, fish, vegetables, fruit, beans, and grains) and cooking them yourself at home in your deep-cleaned, alpha-gal-safe kitchen.

Processed foods and foods with additives often contain hidden mammalian ingredients. These can take the form of:

• Mammalian ingredients with unrecognizable names, like monoglycerides
• Familiar ingredients, like vitamin D3, that you wouldn’t expect to be derived from mammals
• Gelatin and carrageenan used to clarify wine, beer, and some juices
• Carrageenan applied to seafood to mask odor and aid moisture retention
• Processing agents, such as gelatin and carrageenan when used as clarifying agents
  • In the U.S., federal regulatory agencies don’t require manufacturers to list processing agents on packages, unlike ingredients.

Limit the number of processed foods you buy, and buy vegan products when you do.

As described in Determining Tolerance Part II, there is an easier way and a harder way to figure out which foods you may be reacting to:

• The harder way is to continue eating all the processed foods you have always eaten, checking the ingredients of every processed food product you buy.
  • You will soon learn that determining which processed foods contain mammalian-derived ingredients is both difficult and time-consuming.
  • Figuring out which ingredients in which foods triggered your reactions can be close to impossible with this approach due to the delayed nature of alpha-gal reactions.
• The easier way: stop eating non-vegan, processed foods and drinks, at least until you figure out what you can and can’t eat and bring your reactions under control.
  • Once your reactions are under control, add more foods back into your diet, one by one.
• Some people use a hybrid version of these two approaches, primarily eating whole foods but including a few of their favorite processed foods, after checking that they are alpha-gal-free.

• In the U.S., the term “vegan” is not regulated by the FDA and is no guarantee that a product is mammal-free.
• Vegan “certified” products are safer.
• To learn more about interpreting vegan labeling, see Darcie Clement’s explanation here.
• Check vegan products for carrageenan, if you react to it.
• Like carrageenan, agar-agar and nori are made from red algae. They do not seem to be commonly derived from red algae that produce carrageenan, though. It’s unclear whether they may contain any polysaccharides that include the alpha-gal linkage. Many people with AGS report tolerating them, but there are also some reports of reactions.  
• Koji is made from aspergillus fungi, which express alpha-gal. Most of us aren’t bothered by it, but some of us may be.
• Many people with alpha-gal are bothered by gums, like gellan gum, xanthan gum, guar gum, etc.
  • It’s not clear why gums are an issue for some of us, although several hypotheses have been suggested.
  • For people who are bothered by gums, GI issues tend to be the main issue.
  • You might want to avoid gums while you sort things out.

Invite people over for meals instead of eating out. Added benefits will be that you save money and have a healthier diet.

• Find cookbook suggestions on the Food page of this website.
• Join the AlphaGal Kitchen Facebook group for lots of alpha-gal-friendly recipes and cooking tips. There are lots of vegan cooking groups on Facebook, too.
• Follow the Two Alpha Gals on Instagram for fun, alpha-gal friendly recipes.
• Take the Forks over Knives cooking course and become a plant-based home chef in 90 days.

If possible, stop eating out until you have made some progress figuring out what you react to.

• It is challenging to avoid trace amounts of alpha-gal when you eat out due to cross-contamination of pots, pans, grills, etc.
• Prepare food at home and bring it with you to work or social gatherings.
• Invest in a cooler or even a 12-volt portable fridge for the car.
• Air B&Bs with kitchens may work better than hotels or motels when traveling.
• This is a temporary step for most of us. You can try eating out again as you get on top of things.

It gets easier

Learn to read labels. At first, this is a pain, but you will quickly get used to it. These tips will help.

“Vegan” vs. “Vegetarian” 

• Vegetarian≠vegan.
• Vegetarian foods can contain milk and dairy products and byproducts, like whey.

Vegan and vegan certified foods

The terms “vegan” and “plant-based.”

• In the U.S., the terms “vegan” and “plant-based” both mean containing no animal-derived ingredients.
• Unfortunately, the FDA does not regulate either term. Therefore, the presence of these terms on a product’s label is not a guarantee that it is mammal-free.

Look for vegan and plant-based certification symbols

• Products that are certified vegan or plant-based have been verified vegan by independent certification organizations.
• These organizations use symbols to help customers easily spot vegan and plant-based products.
• Keep in mind that even vegan-certified products may be produced on shared lines and can be cross-contaminated with mammalian products.
  • This problem seems especially common with vegan-certified chocolate
• Find a global list of vegan certifiers and their certification marks here.
• To learn more about interpreting vegan labeling, see Darcie Clement’s explanation here.
• See also The Ultimate Guide to Vegan Symbols, Logos, and Signs
• Learn about plant-based certification here.

For vegan certified products, check the ingredient list for carrageenan

• Carrageenan is derived from red algae and is vegan, but it still contains alpha-gal.

Hidden dairy

Dairy labeling laws

Milk is a Big 8 allergen and must be declared on ingredient lists of many, but not all foods and drinks.

• Foods and drinks that do NOT have to be labeled include meat, fish, egg products, fresh fruits and vegetables, and alcoholic drinks.
• Medications, supplements, personal care, and household products also do not need to have dairy ingredients declared on their labels.

 “Non-dairy” vs “dairy-free.”

• • Non-dairy can contain dairy byproducts, like whey and casein.
  • Dairy-free products do not contain dairy but may contain other mammalian byproducts or carrageenan.

Kosher labeling

• Kosher certification is not strict enough for people with allergies, and no guarantee that foods do not contain alpha-gal.
  • We can use kosher labeling to help us avoid foods that contain dairy, but not to help us know which ones definitely do not.
  • Beware of kosher products labeled “pareve.”
    • Many pareve products contain milk protein, which is considered milk-free under kosher guidelines.
  • Look for a “D” or the word “dairy” following the circled K or U on a product label.
    • This means the product contains dairy.

Cruelty-free products

• Cruelty-free products are not tested on animals but may contain ingredients derived from animals.

Phone apps

There are three phone apps that people with alpha-gal syndrome find helpful for figuring out if ingredients listed on the labels of products are alpha-gal-safe. None of these are perfect. You CANNOT count on them to catch every product you might react to, and we caution you NOT to rely on them exclusively. However, they can help you avoid many products that contain alpha-gal, especially while you begin to learn about the names of different byproducts and other problematic ingredients.

Wallet cards

The AGI Mammalian Byproducts Database

Use the searchable AGI Mammalian Byproducts Database to check whether individual ingredients are derived from mammals. For example, you can’t check “Cheerios,” but you can input vitamin D3. We do our best to enter every mammalian byproduct into the database, but we are always going to miss a few. As with the phone apps, you can NOT rely exclusively on this database to ensure that the products you buy are alpha-gal-free, but it’s a good starting place.

Red meat substitutes

Seafood

Vegan

Consider keeping a food diary and/or try an elimination diet to help you figure out which foods are giving you trouble.

Elimination diets

• Elimination diets should be done under the supervision of a dietitian or doctor.
• With an elimination diet, you temporarily stop eating certain foods that may trigger your reactions.
• Elimination diets usually last 2-4 weeks.
• During this period, your doctor will monitor your symptoms.
• If you eliminated the right foods, your symptoms should improve by the end of this period.
• If your symptoms improve, they might encourage you to stop eating dairy products altogether.
• There are lots of resources on elimination diets. This Healthline article is a good starting point.

 Food Journals 

Writing all the foods you eat and the reactions you experience in a journal can help you figure out which foods trigger your reactions. It will also help you determine how long reactions may be delayed and the severity of the reactions.

• Record the date and time for everything you eat or drink.
• Include all foods, and the approximate amount of them, that you eat.
• Don’t exclude anything, even if you know it doesn’t have alpha-gal in it. AGS can trigger additional allergies, and for some people, high histamine foods can trigger reactions as well.
• Be specific, use brand names, so you can check the ingredients again in case you missed something.
• Record the date, time, duration, type, and severity of all your reactions.
• Record any medications you take to treat reactions and how you responded

* Thanks to Jennifer Burton of Alpha-gal Encouragers for her contributions to this section.

Why see a dietitian?

Because of the ubiquitous presence of alpha-gal in foods, people with alpha-gal syndrome often benefit from working with a dietitian. This is especially true for people who:

• Experience dramatic weight loss or at risk of not getting adequate nutrition
• Have other conditions in addition to AGS that limit their diet, such as:
  • Multiple food allergies
  • Diabetes
  • Celiac disease
• Have a history of eating disorders
• Develop nutritional deficiencies
• Cannot determine the sources of their reactions
• Struggle to find foods they can eat.

Registered dietitians vs. nutritionists

Registered dietitians are certified by the Academy of Nutrition and Dietetics.

• A nutritionist is not always certified.

How a dietitian can help

A dietitian can help you:

• Identify foods you can eat.
• Develop meal plans.
• Ensure that you are getting the right amount of calories.
• Avoid deficiencies
• Determine whether you need supplements.

Finding a dietitian

• Ask your allergist or primary care physician to refer you to a dietitian or nutritionist.
• If possible, find one with an understanding of AGS.
• AGS expert Dr. Scott Commins recommends Julie Kennedy.

Keep an eye out for deficiencies

• Vitamin B12 deficiency is especially common in the alpha-gal community.
• Low iron or ferritin levels have also been reported.

Trust your body!

If you react to something, trust your body, stop eating it! There are many ways that alpha-gal can be introduced into a product that seems like it should be alpha-gal free, including:

• Cross-contamination from shared lines
• Undisclosed processing agents
• Waste from pest species like mice and rats

Moreover, every year, the alpha-gal community uncovers more unexpected sources of alpha-gal exposure.

Be aware of other issues

Sometimes your reactions aren’t caused by alpha-gal, but that doesn’t mean you should ignore them. It is not uncommon for people with AGS to develop:

• Tick-borne disease
• Additional food allergies
• Mast cell disorders
• Histamine intolerance

Don’t let people bully you

Don’t second guess yourself, and more importantly, don’t let other people pressure you into eating foods that you know don’t agree with you.

• Believe in yourself
• Find allies
• Be assertive
• Learn to say no!
• Distance yourself from bullies. You deserve better!

First steps

As you get your reactions under control, start adding foods back into your diet.

• Proceed slowly and carefully, adding food items one by one to figure out which are problematic for you.
• Check ALL ingredients in processed foods to ensure they do not contain alpha-gal before reintroducing them to your diet. These approaches may help:
  • Contact manufacturers. This is the most fail-safe approach.
  • Use the  Mammalian Byproducts Database
  • Ask about products in a support group
• Take note of any reactions they elicit.

Next steps

With time, many people’s sensitivity to alpha-gal declines. As a result, you may find that you can reintroduce some foods you previously reacted to, such as dairy, back into your diet.

• Seek a physician’s advice before reintroducing foods back into your diet.
• While reintroducing foods, remember these essential points:
  • Alpha-gal reactions are highly variable. You could not react to an exposure for months at a time and then have a severe reaction.
  • Reactions are delayed by up to 10 hours or more. This makes oral challenges in a physician’s office difficult.
  • New tick bites can make you more sensitive to alpha-gal.
  • Around half the time, people bitten by ticks don’t realize it.
  • There is so such thing as recovery from alpha-gal syndrome, only remission.
• For these reasons, it is the opinion of the creator of this website that the vast majority of people in remission from AGS should stop short of reintroducing the riskiest foods, including mammalian meat and organs. Not all experts agree.

Once you are ready to venture out to restaurants again, learn how to dine out safely.

Guides to dining out with AGS

• Request the Two Alpha Gals Guide to Dining Out Guide here.
• See the AGI Dining Out: A Guide for People with AGS (coming soon) for more information.

Restaurant cards

• Restaurant cards: coming soon.

Resources from step #1

Click on the “+” icon to open

Resources from step #2

Click on the “+” icon to open

1. Commins SP, Satinover SM, Hosen J, Mozena J, Borish L, Lewis BD, Woodfolk JA, Platts-Mills TA. Delayed anaphylaxis, angioedema, or urticaria after consumption of red meat in patients with IgE antibodies specific for galactose-α-1, 3-galactose. Journal of Allergy and Clinical Immunology. 2009 Feb 1;123(2):426-33.

2. Commins S, Lucas S, Hosen J, Satinover SM, Borish L, Platts-Mills TA. Anaphylaxis and IgE antibodies to galactose-alpha-1, 3-galactose (alphaGal): insight from the identification of novel IgE ab to carbohydrates on mammalian proteins. Journal of Allergy and Clinical Immunology. 2008 Feb 1;121(2):S25.

3. Commins SP, James HR, Kelly LA, Pochan SL, Workman LJ, Perzanowski MS, Kocan KM, Fahy JV, Nganga LW, Ronmark E, Cooper PJ. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1, 3-galactose. Journal of Allergy and Clinical Immunology. 2011 May 1;127(5):1286-93.

4. Soh JY, Huang CH, Lee BW. Carbohydrates as food allergens. Asia Pacific Allergy. 2015 Jan 1;5(1):17-24.

5. Levin M, Apostolovic D, Biedermann T, Commins SP, Iweala OI, Platts-Mills TA, Savi E, van Hage M, Wilson JM. Galactose α-1, 3-galactose phenotypes: Lessons from various patient populations. Annals of Allergy, Asthma & Immunology. 2019 Jun 1;122(6):598-602.

6. Platts-Mills TA, Li RC, Keshavarz B, Smith AR, Wilson JM. Diagnosis and management of patients with the α-Gal syndrome. The Journal of Allergy and Clinical Immunology: In Practice. 2020 Jan 1;8(1):15-23.

7. Commins SP. Invited commentary: alpha-gal allergy: tip of the iceberg to a pivotal immune response. Current allergy and asthma reports. 2016 Sep 1;16(9):61.

8. Crispell G, Commins SP, Archer-Hartman SA, Choudhary S, Dharmarajan G, Azadi P, Karim S. Discovery of alpha-gal-containing antigens in North American tick species believed to induce red meat allergy. Frontiers in immunology. 2019 May 17;10:1056.

9. Monzón JD, Atkinson EG, Henn BM, Benach JL. Population and evolutionary genomics of Amblyomma americanum, an expanding arthropod disease vector. Genome biology and evolution. 2016 May 1;8(5):1351-60.

10. Raghavan RK, Peterson AT, Cobos ME, Ganta R, Foley D. Current and future distribution of the lone star tick, Amblyomma americanum (L.)(Acari: Ixodidae) in North America. PLoS One. 2019 Jan 2;14(1):e0209082.

11. Wilson JM, Platts-Mills TA. Red meat allergy in children and adults. Current opinion in allergy and clinical immunology. 2019 Jun 1;19(3):229-35.

12. Commins, SP. (2018). Retrieved from: More people developing red meat allergy from tick bites. CBS News

13. Flaherty MG, Threats M, Kaplan SJ. Patients’ Health Information Practices and Perceptions of Provider Knowledge in the Case of the Newly Discovered Alpha-gal Food Allergy. Journal of Patient Experience. 2020 Feb;7(1):132-9.

14. Flaherty MG, Kaplan SJ, Jerath MR. Diagnosis of life-threatening alpha-gal food allergy appears to be patient driven. Journal of primary care & community health. 2017 Oct;8(4):345-8.

15. Cabezas-Cruz A, Hodžić A, Román-Carrasco P, Mateos-Hernández L, Duscher GG, Sinha DK, Hemmer W, Swoboda I, Estrada-Peña A, De La Fuente J. Environmental and molecular drivers of the α-Gal syndrome. Frontiers in Immunology. 2019 May 31;10:1210.

16. Commins SP, Platts-Mills TA. Tick bites and red meat allergy. Current opinion in allergy and clinical immunology. 2013 Aug;13(4):354.

17. Stoltz LP, Cristiano LM, Dowling AP, Wilson JM, Platts-Mills TA, Traister RS. Could chiggers be contributing to the prevalence of galactose-alpha-1, 3-galactose sensitization and mammalian meat allergy?. The journal of allergy and clinical immunology. In practice. 2019 Feb;7(2):664.

18. Arkestål K, Sibanda E, Thors C, Troye-Blomberg M, Mduluza T, Valenta R, Grönlund H, van Hage M. Impaired allergy diagnostics among parasite-infected patients caused by IgE antibodies to the carbohydrate epitope galactose-α1, 3-galactose. Journal of Allergy and Clinical Immunology. 2011 Apr 1;127(4):1024-8.

19. Chinuki Y, Ishiwata K, Yamaji K, Takahashi H, Morita E. Haemaphysalis longicornis tick bites are a possible cause of red meat allergy in Japan. Allergy. 2016 Mar;71(3):421-5.

20. Hashizume H, Fujiyama T, Umayahara T, Kageyama R, Walls AF, Satoh T. Repeated Amblyomma testudinarium tick bites are associated with increased galactose-α-1, 3-galactose carbohydrate IgE antibody levels: a retrospective cohort study in a single institution. Journal of the American Academy of Dermatology. 2018 Jun 1;78(6):1135-41.

21. Bianchi, John (2019). Personal communication

22. Morisset M, Richard C, Astier C, Jacquenet S, Croizier A, Beaudouin E, Cordebar V, Morel‐Codreanu F, Petit N, Moneret‐Vautrin DA, Kanny G. Anaphylaxis to pork kidney is related to IgE antibodies specific for galactose‐alpha‐1, 3‐galactose. Allergy. 2012 May;67(5):699-704.

23. Fischer J, Hebsaker J, Caponetto P, Platts-Mills TA, Biedermann T. Galactose-alpha-1, 3-galactose sensitization is a prerequisite for pork-kidney allergy and cofactor-related mammalian meat anaphylaxis. Journal of allergy and clinical immunology. 2014 Sep 1;134(3):755-9.

24. Fischer J, Yazdi AS, Biedermann T. Clinical spectrum of α-Gal syndrome: from immediate-type to delayed immediate-type reactions to mammalian innards and meat. Allergo journal international. 2016 Mar 1;25(2):55-62.

25. McPherson TB, Liang H, Record RD, Badylak SF. Galα (1, 3) Gal epitope in porcine small intestinal submucosa. Tissue engineering. 2000 Jun 1;6(3):233-9.

26. Fujiwara M, Araki T. Immediate anaphylaxis due to beef intestine following tick bites. Allergology International. 2019;68(1):127-9.

27. Caponetto P, Fischer J, Biedermann T. Gelatin-containing sweets can elicit anaphylaxis in a patient with sensitization to galactose-α-1, 3-galactose. The Journal of Allergy and Clinical Immunology: In Practice. 2013 May 1;1(3):302-3.

28. Mullins RJ, James H, Platts-Mills TA, Commins S. Relationship between red meat allergy and sensitization to gelatin and galactose-α-1, 3-galactose. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1334-42.

29. Kaman K, Robertson D. ALPHA-GAL ALLERGY; MORE THAN MEAT?. Annals of Allergy, Asthma & Immunology. 2018 Nov 1;121(5):S115.

30. Chung CH, Mirakhur B, Chan E, Le QT, Berlin J, Morse M, Murphy BA, Satinover SM, Hosen J, Mauro D, Slebos RJ. Cetuximab-induced anaphylaxis and IgE specific for galactose-α-1, 3-galactose. New England journal of medicine. 2008 Mar 13;358(11):1109-17.

31. Berg EA, Platts-Mills TA, Commins SP. Drug allergens and food—the cetuximab and galactose-α-1, 3-galactose story. Annals of Allergy, Asthma & Immunology. 2014 Feb 1;112(2):97-101.

32. Dunkman WJ, Rycek W, Manning MW. What does a red meat allergy have to do with anesthesia? Perioperative management of alpha-gal syndrome. Anesthesia & Analgesia. 2019 Nov 1;129(5):1242-8.

33. Pfützner W, Brockow K. Perioperative drug reactions–practical recommendations for allergy testing and patient management. Allergo journal international. 2018 Jun 1;27(4):126-9.

34. Dewachter P, Kopac P, Laguna JJ, Mertes PM, Sabato V, Volcheck GW, Cooke PJ. Anaesthetic management of patients with pre-existing allergic conditions: a narrative review. British journal of anaesthesia. 2019 Jul 1;123(1):e65-81.

35. Popescu FD, Cristea OM, IONICĂ FE, Vieru M. DRUG ALLERGIES DUE TO IgE SENSITIZATION TO α-GAL. magnesium. 2018;2017:47-8.

36. Swiontek K, Morisset M, Codreanu-Morel F, Fischer J, Mehlich J, Darsow U, Petitpain N, Biedermann T, Ollert M, Eberlein B, Hilger C. Drugs of porcine origin—A risk for patients with α-gal syndrome?. The Journal of Allergy and Clinical Immunology: In Practice. 2019 May 1;7(5):1687-90.

37. Vidal C, Mendez-Brea P, Lopez-Freire S, Gonzalez-Vidal T. Vaginal Capsules: An Unsuspected Probable Source of Exposure to α-Gal. Journal of investigational allergology & clinical immunology. 2016;26(6):388.

38. Muglia C, Kar I, Gong M, Hermes-DeSantis ER, Monteleone C. Anaphylaxis to medications containing meat byproducts in an alpha-gal sensitized individual. The journal of allergy and clinical immunology. In practice. 2015;3(5):796.

39. Akella K, Patel H, Wai J, Roppelt H, Capone D. Alpha Gal-Induced Anaphylaxis to Herpes Zoster Vaccination.  Chest. 2017 Oct 1;152(4):A6.

40. Bakhtiar MF, Leong KW, Kwok FY, Hui MT, Tang MM, Joseph CT, Bathumana‐Appan PP, Nagum AR, ZHM Y, Murad S. P66: ALLERGIC REACTION TO BOVINE GELATIN COLLOID: THE ROLE OF IMMUNOGLOBULIN E TOWARDS GALACTOSE‐ALPHA‐1, 3‐GALACTOSE: IMPLICATIONS BEYOND RED MEAT ALLERGIES. Internal Medicine Journal. 2017 Sep;47:24-.

41. Bradfisch F, Pietsch M, Forchhammer S, Strobl S, Stege HM, Pietsch R, Carstens S, Schäkel K, Yazdi A, Saloga J. Case series of anaphylactic reactions after rabies vaccinations with gelatin sensitization. Allergo Journal International. 2019 Jun 1;28(4):103-6.

42. Stone CA, Commins SP, Choudhary S, Vethody C, Heavrin JL, Wingerter J, Hemler JA, Babe K, Phillips EJ, Norton AE. Anaphylaxis after vaccination in a pediatric patient: further implicating alpha-gal allergy. The Journal of Allergy and Clinical Immunology: In Practice. 2019 Jan 1;7(1):322-4.

43. Stone CA, Hemler JA, Commins SP, Schuyler AJ, Phillips EJ, Peebles RS, Fahrenholz JM. Anaphylaxis after zoster vaccine: Implicating alpha-gal allergy as a possible mechanism. Journal of Allergy and Clinical Immunology. 2017 May 1;139(5):1710-3.

44. Pattanaik D, Lieberman P, Lieberman J, Pongdee T, Keene AT. The changing face of anaphylaxis in adults and adolescents. Annals of Allergy, Asthma & Immunology. 2018 Nov 1;121(5):594-7.

45. Ankersmit HJ, Copic D, Simader E. When meat allergy meets cardiac surgery: A driver for humanized bioprosthesis. The Journal of thoracic and cardiovascular surgery. 2017 Oct 1;154(4):1326-7.

46. Hawkins RB, Frischtak HL, Kron IL, Ghanta RK. Premature bioprosthetic aortic valve degeneration associated with allergy to galactose‐alpha‐1, 3‐galactose. Journal of cardiac surgery. 2016 Jul;31(7):446-8.

47. Kleiman AM, Littlewood KE, Groves DS. Delayed anaphylaxis to mammalian meat following tick exposure and its impact on anesthetic management for cardiac surgery: a case report. A&A Practice. 2017 Apr 1;8(7):175-7.

48. Mozzicato SM, Tripathi A, Posthumus JB, Platts-Mills TA, Commins SP. Porcine or bovine valve replacement in three patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1, 3-galactose. The journal of allergy and clinical immunology. In practice. 2014 Sep;2(5):637.

49. Mangold A, Szerafin T, Hoetzenecker K, Hacker S, Lichtenauer M, Niederpold T, Nickl S, Dworschak M, Blumer R, Auer J, Ankersmit HJ. Alpha-Gal specific IgG immune response after implantation of bioprostheses. The Thoracic and cardiovascular surgeon. 2009 Jun;57(04):191-5.

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54. Tobacman JK. The common food additive carrageenan and the alpha-gal epitope. Journal of Allergy and Clinical Immunology. 2015 Dec 1;136(6):1708-9.

55. Tarlo SM, Dolovich J, Listgarten C. Anaphylaxis to carrageenan: A pseudo–latex allergy. Journal of allergy and clinical immunology. 1995 May 1;95(5):933-6.

56. Steinke JW, Platts-Mills TAE, Schuyler A, Commins SP. Reply to “The common food additive carrageenan and the alpha-gal epitope”. Journal of Allergy and Clinical Immunology. 2015 Oct 28;136(6):1709-10

57. Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Review of Clinical Immunology. 2020 Jul 9:1-1.

58. Galili, U., & Avila, J. L. (Eds.). (2012). α–Gal and Anti–Gal: α1, 3–Galactosyltransferase, α–Gal Epitopes, and the Natural Anti–Gal Antibody Subcellular Biochemistry (Vol. 32). Springer Science & Business Media.

59. Fischer J, Lupberger E, Hebsaker J, Blumenstock G, Aichinger E, Yazdi AS, Reick D, Oehme R, Biedermann T. Prevalence of type I sensitization to alpha‐gal in forest service employees and hunters. Allergy. 2017 Oct;72(10):1540-7.

60. Kimpel D, Wilson J, Lewis J. SAT0456 SERO-REACTIVITY TO GALACTOSE-ALPHA-1,3-GALACTOSE AND CLINICAL PRESENTATIONS OF PATIENTS SEEN IN A RHEUMATOLOGY OUTPATIENT PRACTICE. Annals of the Rheumatic Diseases 2019 Jun 15;78:1317-8.

61. Bianchi J, Walters A, Fitch ZW, Turek JW. Alpha-gal syndrome: Implications for cardiovascular disease. Global Cardiology Science and Practice. 2020 Feb 9;2019(3).

62. Carter MC, Ruiz‐Esteves KN, Workman L, Lieberman P, Platts‐Mills TA, Metcalfe DD. Identification of alpha‐gal sensitivity in patients with a diagnosis of idiopathic anaphylaxis. Allergy. 2018 May;73(5):1131-4.

63. Binder AM, Commins SP, Altrich ML, et al. Diagnostic testing for galactose-alpha-1,3-galactose, United States, 2010 to 2018. Ann Allergy Asthma Immunol. 2021;126(4):411-416.e1.

64. I-TICK Surveillance. Retrieved from: https://twitter.com/ITickUIUC/status/1282799807996854278

65. Wickner PG, Commins SP. The first 4 Central American cases of delayed meat allergy with galactose-alpha-1, 3-galactose positivity clustered among field biologists in Panama. Journal of Allergy and Clinical Immunology. 2014 Feb 1;133(2):AB212.

66. Ohshita N, Ichimaru Y, Gamoh S, Tsuji K, Kishimoto N, Tsutsumi YM, Momota Y. Management of infusion reactions associated with cetuximab treatment: A case report. Molecular and Clinical Oncology. 2017 Jun 1;6(6):853-5.

67. Stein D, Schuyler A, Commins S, Behm B, Chitnavis M. P-002 YI First Dose IgE-Mediated Allergy to Infliximab Due to Galactose-α-1, 3-Galactose Allergy. Inflammatory Bowel Diseases. 2016 Mar 1;22:S9-10.

68. Van Tine BA, Govindarajan R, Attia S, Somaiah N, Barker SS, Shahir A, Barrett E, Lee P, Wacheck V, Ramage SC, Tap WD. Incidence and management of olaratumab infusion-related reactions. Journal of oncology practice. 2019 Nov;15(11):e925-33.

69. Venturini M, Lobera T, Sebastián A, Portillo A, Oteo JA. IgE to α-Gal in Foresters and Forest Workers From La Rioja, North of Spain. Journal of investigational allergology & clinical immunology. 2018;28(2):106.

70. Apostolovic D, Tran TA, Hamsten C, Starkhammar M, Cirkovic Velickovic T, van Hage M. Immunoproteomics of processed beef proteins reveal novel galactose‐α‐1, 3‐galactose‐containing allergens. Allergy. 2014 Oct;69(10):1308-15.

71. Khora SS, Navya P. Bioactive Polysaccharides from Marine Macroalgae. Encyclopedia of Marine Biotechnology. 2020 Aug 4.

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73. Hodžić A, Mateos-Hernández L, Fréalle E, Román-Carrasco P, Alberdi P, Pichavant M, Risco-Castillo V, Le Roux D, Vicogne J, Hemmer W, Auer H. Infection with Toxocara canis Inhibits the Production of IgE Antibodies to α-Gal in Humans: Towards a Conceptual Framework of the Hygiene Hypothesis?. Vaccines. 2020 Jun;8(2):167.

74. Taguchi T, Kitajima K, Muto Y, Inoue S, Khoo KH, Morris HR, Dell A, Wallace RA, Selman K, Inoue Y. A precise structural analysis of a fertilization-associated carbohydrate-rich glycopeptide isolated from the fertilized eggs of euryhaline killi fish (Fundulus heteroclitus). Novel penta-antennary N-glycan chains with a bisecting N-acetylglucosaminyl residue. Glycobiology. 1995 Sep 1;5(6):611-24.

75. Shao Y, Yu Y, Pei CG, Qu Y, Gao GP, Yang JL, Zhou Q, Yang L, Liu QP. The expression and distribution of α-Gal gene in various species ocular surface tissue. International journal of ophthalmology. 2012;5(5):543.

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79. Wilson JM, Nguyen AT, Schuyler AJ, Commins SP, Taylor AM, Platts-Mills TA, McNamara CA. IgE to the mammalian oligosaccharide galactose-α-1, 3-galactose is associated with increased atheroma volume and plaques with unstable characteristics—brief report. Arteriosclerosis, thrombosis, and vascular biology. 2018 Jul;38(7):1665-9.

80. Wilson JM, McNamara CA, Platts-Mills TA. IgE, α-Gal and atherosclerosis. Aging (Albany NY). 2019 Apr 15;11(7):1900.

81. Tina Merritt, MD, personal communication.

82. Hodgeman N, Horn CL, Paredes A. An Unusual Mimicker of Irritable Bowel Disease: 1855. American Journal of Gastroenterology. 2019 Oct 1;114(2019 ACG Annual Meeting Abstracts):S1039.

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84. Mabelane T, Basera W, Botha M, Thomas HF, Ramjith J, Levin ME. Predictive values of alpha‐gal IgE levels and alpha‐gal IgE: Total IgE ratio and oral food challenge‐proven meat allergy in a population with a high prevalence of reported red meat allergy. Pediatric Allergy and Immunology. 2018 Dec;29(8):841-9.

85. Armstrong P, Binder A, Amelio C, Kersh G, Biggerstaff B, Beard C, Petersen L, Commins S. Descriptive Epidemiology of Patients Diagnosed with Alpha-gal Allergy—2010–2019. Journal of Allergy and Clinical Immunology. 2020 Feb 1;145(2):AB145.

86. Pointreau Y, Commins SP, Calais G, Watier H, Platts-Mills TA. Fatal infusion reactions to cetuximab: role of immunoglobulin E–mediated anaphylaxis. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2012 Jan 20;30(3):334.

87. van Nunen S. Tick-induced allergies: mammalian meat allergy, tick anaphylaxis and their significance. Asia Pacific Allergy. 2015 Jan 1;5(1):3-16.

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92. Platts-Mills TA, Commins SP, Biedermann T, van Hage M, Levin M, Beck LA, Diuk-Wasser M, Jappe U, Apostolovic D, Minnicozzi M, Plaut M. On the cause and consequences of IgE to galactose-α-1, 3-galactose: a Report from the National Institute of Allergy and Infectious Disease Workshop on Understanding IgE-Mediated Mammalian Meat Allergy. Journal of Allergy and Clinical Immunology. 2020 Feb 10.

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94. Hilger C, Fischer J, Swiontek K, Hentges F, Lehners C, Eberlein B, Morisset M, Biedermann T, Ollert M. Two galactose‐α‐1, 3‐galactose carrying peptidases from pork kidney mediate anaphylactogenic responses in delayed meat allergy. Allergy. 2016 May;71(5):711-9.

95. Iweala OI, Choudhary SK, Addison CT, Batty CJ, Kapita CM, Amelio C, Schuyler AJ, Deng S, Bachelder EM, Ainslie KM, Savage PB. Glycolipid-mediated basophil activation in alpha-gal allergy. Journal of Allergy and Clinical Immunology. 2020 Feb 20.

96. Iweala O, Brennan PJ, Commins SP. Serum IgE specific for alpha-Gal sugar moiety can bind glycolipid. Journal of Allergy and Clinical Immunology. 2017 Feb 1;139(2):AB88.

97. Iweala OI, Choudhary SK, Addison CT, Batty CJ, Kapita CM, Amelio C, Schuyler AJ, Deng S, Bachelder EM, Ainslie KM, Savage PB. Glycolipid-mediated basophil activation in alpha-gal allergy. Journal of Allergy and Clinical Immunology. 2020 Feb 20.

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100.  Wilson JM, Platts-Mills TA. The oligosaccharide galactose-α-1, 3-galactose and the α-Gal syndrome: insights from an epitope that is causal in immunoglobulin E-mediated immediate and delayed anaphylaxis. Eur Med J. 2018;3:89-98.

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104. Chinuki Y, Morita E, Takahashi H. IgE antibodies to galactose-a-1,3-galactose, an epitope of red meat allergen, cross-react with a novel flounder roe allergen. J Investig Allergol Clin Immunol. Published online October 15, 2021:0.

105. Shao Y, Yu Y, Pei C-G, et al. The expression and distribution of α-Gal gene in various species ocular surface tissue. Int J Ophthalmol. 2012;5(5):543.

106. Murangi T, Prakash P, Moreira BP, et al. Ascaris lumbricoides and ticks associated with sensitisation to Galactose α1,3-galactose and elicitation of the alpha-gal syndrome. J Allergy Clin Immunol. Published online July 29, 2021. doi:10.1016/j.jaci.2021.07.018

107. Mateos-Hernández L, Risco-Castillo V, Torres-Maravilla E, et al. Gut Microbiota Abrogates Anti-α-Gal IgA Response in Lungs and Protects against Experimental Aspergillus Infection in Poultry. Vaccines (Basel). 2020;8(2). doi:10.3390/vaccines8020285

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110. Gowda DC, Glushka J, van Halbeek H, Thotakura RN, Bredehorst R, Vogel C-W. N-linked oligosaccharides of cobra venom factor contain novel α (1-3) galactosylated Lex structures. Glycobiology. 2001;11(3):195-208.

111. Ramasamy R. Mosquito vector proteins homologous to α1-3 galactosyl transferases of tick vectors in the context of protective immunity against malaria and hypersensitivity to vector bites. Parasit Vectors. 2021;14(1):303.

112. Fukunaga T, Tanaka N, Furumoto T, et al. Substrate specificities of α1,2- and α1,3-galactosyltransferases and characterization of Gmh1p and Otg1p in Schizosaccharomyces pombe. Glycobiology. Published online April 28, 2021. doi:10.1093/glycob/cwab028

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114. Scott Commins, MD, PhD, personal communication

115. Perusko M, Apostolovic D, Kiewiet MB, Grundström J, Hamsten C, Starkhammar M, Cirkovic Velickovic T, van Hage M. Bovine γ‐globulin, lactoferrin, and lactoperoxidase are relevant bovine milk allergens in patients with α‐Gal syndrome.  Allergy. 2021 May 3.

116. Croglio MP, Commins SP, McGill SK. Isolated Gastrointestinal Alpha-gal Meat Allergy Is a Cause for Gastrointestinal Distress Without Anaphylaxis. Gastroenterology. 2021 May 1;160(6):2178-80.

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