Alcohol associated with more severe anaphylaxis in nut allergy
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Key takeaways:
- Peanuts, shellfish and tree nuts were the most common food triggers in anaphylaxis.
- The combination of nuts used in drinks and alcohol’s role as an antihistamine trigger may lead to more severe reactions.
Symptomology varies among adults with anaphylaxis depending on the trigger, according to a study published in International Archives of Allergy and Immunology.
For example, patients with nut allergies may experience more severe reactions when they drink alcohol, Roy Khalaf, fourth-year medical student, Faculty of Medicine and Health Sciences, McGill University, and colleagues wrote.
“The majority of studies in the literature concentrate on pediatric anaphylaxis, leaving a gap in data regarding adult cases,” Khalaf told Healio.
Moshe Ben-Shoshan, MD, MSc, assistant professor in the division of allergy and clinical medicine at McGill, led the collaboration with multiple physicians across Canada, Khalaf continued, including access to a database of adults with anaphylaxis presenting at EDs.
“These cases were stratified by triggers, allowing us to analyze their symptoms, co-morbidities and management approaches,” Khalaf said.
The study used data from the Cross Canada Anaphylaxis Registry, including eight EDs and one electronic medical service, for 1,135 adults (median age, 35.5 years; 38.4% men) who presented with anaphylaxis between April 2011 and November 2023.
Median ages by anaphylaxis trigger included 51.8 years for venom, 49.1 years for drug and 30.7 years for food. Specific median ages for food triggers ranged from a high of 52.1 years for soy to lows of 24.6 years for peanut and 23.5 years for milk.
Also, 15.1% of these patients had comorbid asthma. Anaphylaxis symptoms included pruritus (61.8%), angioedema (55.4%), urticaria (55.3%) and throat tightness (54.4%), with 23.7% of patients reporting no cutaneous symptoms.
Severity was mild for 7.6% of patients, moderate for 73.4% and severe for 18.9%, the researchers said, although they added that data came exclusively from EDs, so there was a lack of data pertaining to less severe reactions.
Food was the most common trigger (53.7%), followed by drugs (20.2%) and venom (6.3%). The most common triggers among foods included peanut (13.5%), shellfish (10.2%), tree nut (8.7%) and undefined nuts (4.1%).
The most common triggers among drugs were antibiotics (> 10.5%), with amoxicillin (4.7%) leading this category. Ingestion led to anaphylaxis in 77.3% of the drug-induced cases, and 18.8% of reactions were from parenteral administration.
The study indicated 168 hospital admissions following anaphylaxis as well, with 35.7% of these cases triggered by drugs, and 18 admissions to the ICU, with 44.4% of these cases triggered by drugs.
Hypotension was associated with drugs (adjusted OR = 1.2; 95% CI, 1.11-1.3), particularly intravenously administered drugs (aOR = 2.5; 95% CI, 1.32-4.41), and venom (aOR = 1.08; 95% CI, 1.03-1.13). Throat tightness was associated with tree nuts (aOR = 1.04; 95% CI, 1.01-1.06).
Triggers among the severe reactions included drugs (30.1%), venom (27.8%), tree nuts (18.9%), peanuts (14.6%), and undefined nuts (10.6%). Alcohol was associated with severe undefined nut-induced anaphylaxis as well (aOR = 1.51; 95% CI, 1.04-2.19).
“While alcohol is recognized as a cofactor that can exacerbate the severity of anaphylactic reactions, it was surprising to find a particular association with nut-induced anaphylaxis,” Khalaf said.
Explanations for the association between alcohol- and nut-induced anaphylaxis included ethanol’s vasodilation effect, which can lead to more severe shock from food allergy, the researchers said.
Further, the elevated acetaldehyde levels that follow alcohol consumption could induce airway mast cells to release histamine, increasing reaction severity, the researchers continued.
The nuts that often are used as a flavoring option in alcoholic drinks may combine with alcohol’s tendency to release antihistamines, also leading to more severe reactions, the researchers said.
“This observation raises questions about the safety of artificial flavorings in alcohol, which often contain nut-derived components, for patients with nut allergies,” Khalaf said.
Alcohol may be a cofactor in more severe forms of pollen food syndrome after the ingestion of tree nuts as well, the researchers added.
The researchers did not note any significant associations between severe reactions and exercise for any of the triggers, nor did they report any significant associations between alcohol consumption, asthma or other known comorbidities and other triggers.
“In our registry, 210 patients had a known allergy to food, alcohol or venom,” Khalaf said. “However, only 51 patients (24.3%) used epinephrine during their reaction outside the hospital.”
Khalaf remarked that this low percentage was notable because protocols recommend that anyone with a history of allergic reactions should carry an epinephrine autoinjector.
Outpatient treatment included epinephrine autoinjectors (27.8%), antihistamines (42.1%) and corticosteroids (8.7%). Treatment in the hospital also included epinephrine autoinjectors (43.3%), antihistamines (73.7%) and corticosteroids (74.8%).
Patients with peanut-induced anaphylaxis were more likely to get epinephrine autoinjectors in outpatient settings (aOR = 3.25; 95% CI, 2.03-5.2). Patients with anaphylaxis induced by tree nuts were more likely to get epinephrine autoinjectors with inpatient treatment (aOR = 2.05; 95% CI, 1.16-3.64).
During outpatient treatment, patients with drug-induced anaphylaxis were less likely to get antihistamine (aOR = 0.68; 95% CI, 0.48-0.89), and those with tree nut-induced anaphylaxis were more likely to get it (aOR = 1.81; 95% CI, 1.03-3.19).
Inpatient treatment including antihistamine was less likely for patients with anaphylaxis induced by peanuts (aOR = 0.46; 95% CI, 0.29-0.74) and tree nuts (aOR = 0.48; 95% CI, 0.26-0.83).
Overall, the researchers attributed food’s role as the leading trigger in anaphylaxis, particularly peanut, to the increased prevalence of food allergy worldwide. However, they cautioned that these associations do not imply a universal early warning system in anaphylaxis diagnosis.
Adding that validated diagnostic criteria for anaphylaxis remain crucial for swift diagnosis and appropriate treatment, the researchers reminded clinicians should practice clinical vigilance and focus on comprehensive assessment of each patient, with rapid administration of epinephrine when it is indicated.
“Educating patients on the proper use of epinephrine is one of the most crucial takeaways from anaphylaxis research,” Khalaf said.
The underuse of epinephrine observed in this study aligned with results from previous research, Khalaf continued, adding that he and his colleagues also have published findings indicating reductions in ICU mortality among patients with anaphylaxis who receive epinephrine prior to arriving at the hospital.
“Additionally, it is vital to emphasize the importance of teaching patients with known allergies to carefully check all ingredients, not only in their food but also in alcoholic beverages, as hidden flavorings may pose a risk,” Khalaf said.
Khalaf and his colleagues are now comparing anaphylaxis between elderly patients and non-elderly adults, and he reports that findings so far are “intriguing.” He expects this study to be published in the first quarter of 2025.
Reference:
- Study links alcohol consumption to more severe nut allergy reaction. https://www.mcgill.ca/lin-centre/channels/news/study-links-alcohol-consumption-more-severe-nut-allergy-reaction-362237. Published Dec. 19, 2024. Accessed Dec. 23, 2024.
For more information:
Roy Khalaf can be reached at roy.khalaf@mail.mcgill.ca.
Perspective
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These findings are significant but not entirely surprising. We already know that alcohol can affect how our immune system works. It can make the body’s reactions to allergens more unpredictable and severe. Alcohol also dilates blood vessels and can lower blood pressure, which may make symptoms of an allergic reaction such as anaphylaxis more dangerous.
What’s particularly important here is that this study provides concrete evidence of a link between alcohol consumption and the severity of nut allergies, which emphasizes the need for increased awareness among patients and health care providers.
Individuals with severe allergies often report worse symptoms when alcohol is involved. There are some cases where someone with a manageable nut allergy suddenly experiences a much more severe reaction after drinking. Alcohol tends to impair judgment as well, which could delay how quickly someone recognizes or responds to symptoms. This study aligns with what many physicians have observed clinically, reinforcing the need for those with known allergies to take extra precautions when consuming alcohol.
Doctors can use this information to educate patients about the risks of mixing alcohol with allergies. It is important for doctors and patients to have honest conversations about how alcohol can amplify allergic reactions. For patients with severe allergies, this study supports recommending strategies such as avoiding alcohol altogether, especially in social situations where allergens may be present. Clinicians can also emphasize the importance of carrying an epinephrine autoinjector at all times and ensuring others around patients know how to use it.
The next step in this research should be exploring the exact biological mechanisms behind this connection. Why does alcohol make these reactions worse? Is it due to immune suppression, blood flow changes, or some combination of factors? Larger, more diverse studies would also be helpful to confirm these findings across different populations and types of allergens. I would also like to see research focused on how different amounts or types of alcohol affect allergic reactions, as this could help doctors give more tailored advice to patients.
Perspective
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The findings are significant because this is the largest study that has looked at this link between alcohol intake and the severity of allergic reactions. However, it is not that surprising, as we know from previous anecdotal observations that the severity of tree nut-induced allergic reactions and anaphylaxis can vary based on certain cofactors. These factors were always thought to include alcohol consumption, exercise and other comorbidities such as anxiety and asthma. It is worth noting, though, that the study only looked at ED patients, and they may have had a serious reaction anyway. We do not know the effect of alcohol on the milder or unreported cases in the community.
What is particularly new, however, is the suggestion that even artificially nut-flavored drinks could cause severe allergic reactions as individuals are exposed to trace allergens. This shows the need for better education for both the public and for health care professionals in the advice given.
Taking a full history is a vital part of the allergy consultation, and one of the reasons for this is to establish allergy triggers.I have noticed in my patients with food allergies that more of the severe reactions happen when they have alcohol with a meal. Part of the reason behind this may be that alcohol causes vasodilatation, so the allergens get absorbed more quickly and in greater quantity. This can heighten the immune system’s response if it is already sensitized and releases more inflammatory mediators such as histamine. This can also explain why even artificially nut flavored alcohol drinks can cause a reaction, as they may still contain trace allergens.
Patient education is important in making the public aware of the increased risks for a severe allergic reaction when combining food with alcohol. This advice is especially pertinent for those with multiple food allergies or those who regularly eat outside the home and cannot entirely avoid potential allergens. In such high risk, it may be prudent to counsel patients either to avoid combining food with alcohol or to be more aware of the potential dangers.
Next, research can potentially hone down on the type and amount of alcohol consumed. We do not know whether low-alcohol beverages carry the same risk as spirits, for example. Identifying the exact mechanism for the increased risk for anaphylaxis could also be beneficial and potentially provide more targeted therapeutic options.
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