Episode #332 Alpha-Gal Syndrome: What Every Anesthesia Professional Needs to Know

Hello and welcome to the Anesthesia Patient Safety Podcast. I’m your host, Alli Bechtel. Today, we’re talking about a condition that every anesthesia professional should have on their radar: Alpha-Gal Syndrome, a potentially serious allergy to a carbohydrate found in non-primate mammalian tissues that can have important implications for medications, medical devices, and perioperative care.

Because alpha-gal–containing products can be found in places that may not always be obvious, recognizing the risks and knowing how to safely care for patients with Alpha-Gal Syndrome can be challenging for anesthesia professionals.

Before we dive further into the episode today, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare, we wouldn’t be able to do all that we do without you!”

Joining me to help us navigate this important patient-safety issue is Dr. Maziar Nourian, an assistant professor of anaesthesiology and perioperative medicine at the University of California Los Angeles where he practices cardiac anesthesia. Today, we’ll discuss what anesthesia professionals need to know about Alpha-Gal Syndrome, how it can affect perioperative care, and practical strategies for identifying and managing these patients safely.

Dr. Nourian, welcome to the Anesthesia Patient Safety Podcast.

[Interview Show]

NOURIAN 1:37

Thank you so much for having me. My name is Maziar Nourian. I go by Mazi with most of my friends. I’m a cardiac anaesthesiologist and assistant professor at uh UCLA in Los Angeles. Went to medical school at University of Utah and then completed uh anesthesia training at Vanderbilt University Medical Center, um, where I first was introduced into Alpha Gaul syndrome, and then further did my training in cardiothoracic anesthesia at Cedar Sinai in Los Angeles, currently clinically focusing on taking care of cardiac patients and complex surgical procedures. Um, and then a major focus of my academic work has been patient safety and particularly helping guide patients with Alpha Gal syndrome uh through the perioperative setting.

Alli 2:22

Well, and since this is the Anesthesia Patient Safety podcast, we’d like to start the conversation off about patient safety. So, what first got you interested in patient safety in your practice?

NOURIAN 2:33

Yeah, uh I think what drew me to patient safety was realizing that like so many adverse events are not necessarily caused by like one mistake, but you know, there’s so there’s all these like hidden things that could happen in just a routine system that could cascade into uh you know harm in patients. And so Alpha Gal is a perfect example of that. And um, I first encountered uh patients with Alpha Gal syndrome at Vanderbilt in Nashville, which is one of the endemic areas for Alpha Gal syndrome. And I weirdly enough kept getting more and more patients. And at the time I was a resident, all of a sudden I somehow became kind of like the local guru for Alpha Gal. Every resident attending would ask me, like, hey, what is this? What do I need to do? Just because I had so many patients that came up with this. And so from there decided to start writing about this a little bit more. But most importantly, I think as I got further into this work, I got connected with Alpha Gal groups and was able to actually talk to patients who are affected by Alpha Gal. And the most, I guess, beneficial thing was like seeing how much impact this has, how scared people are, how uh, you know, patient safety initiatives actually does mean a lot of difference to um our patients that we take care of.

Alli 3:45

Oh, that’s so interesting. And really one of the big focuses of the APSF when we talk about big patient safety issues is the patient experience and keeping the patient in the center of it. And it sounds like that just kind of developed naturally for you as you progressed with your research. So, what exactly is Alpha Gal syndrome and why has this become such a hot topic for anesthesia professionals and our patients?

NOURIAN 4:12

Kind of a mouthful Alpha Gal syndrome. Um if you remember back from medical school or you know, back to basic biology, uh, this is the alpha 1-3 galactose uh molecule. And that’s actually a carbohydrate that’s found in non-primate mammals, including cows, pigs, sheep, and deer. Importantly, alpha gal syndrome is an IgE-mediated response to that carbohydrate. And I keep saying carbohydrate because that’s important, and I’ll explain why that is in terms of the food allergy world. But so it’s a type one sensitivity reaction to this. And so why this is becoming important, at least particularly in the United States, is that this is starting to become more and more common as we’re seeing an increase in tick bites. So right now, Alpha Gal syndrome has been associated with the lone star tick, which is pretty endemic in the southeast part of the United States. But as climate change is happening and things are getting warmer, you’re starting to see ticks pop up all over. Actually, there’s been described cases of Alpha Gal syndrome all over the world. Currently, right now, there’s about 450,000 cases that have been uh described, but I’m sure there’s a lot more. And so what happens is that once a person develops this alpha gal IgE after exposure to a tick bite, they get sensitized to any sort of mammalian meat products or mammalian meat. And so from like a food perspective, that could mean something that kind of mimics something like a red meat allergy. So every time they have bacon, you know, steak, you know, whatever it may be, you know, four to six hours later, they’re starting to have upset stomach, maybe some rash you need a carry on, such like that. Typically, each progressive exposure to these mammalian meat products or just meat in general makes the symptoms worse. But why that’s important in anesthesia is that while we’re not injecting people with meat, we are uh potentially giving people uh inactive ingredients that are made from mammalian meat products. And especially since we’re giving them IV, that’s a lot more not necessarily lethal, but it can be, but a lot more dangerous because uh it’s you know, bypassing the enteric route and just directly going into the IV. Why that’s important in the perioperative environment is just reducing patients’ exposure to these mammalian meat products and helping protect our patients with uh alpha gal syndrome.

Alli 6:34

Is this different than a conventional food allergy?

NOURIAN 6:37

Uh yeah, yeah. So um just uh just to take a one little sidestep, right now it’s listed as the tenth most common food allergy, but it’s different than food allergies in the sense that most food allergies are actually an IgE response to proteins. Um, where as I was mentioning before, this isn’t uh IgE response to a carbohydrate, the sugar. And why that’s important is that most people will show like symptoms or anaphylaxis to you know foods that they’re allergic to anywhere from like 30 to 60 minutes after ingesting. Whereas in the Alpha Gal world, we’re seeing people, you know, show symptoms four to six hours later. So it’s like they may wake up in the middle of the night after dinner saying, like, oh, I’m having flushing syndrome uh or you know, rashes or hives and stuff like that. One last like thing is that the symptoms of Alpha Gal are kind of inconsistent. So one person may respond a little bit differently than the other person, and there’s kind of a wide phenotype of how people present. Of note, as we know so far, exposure to alcohol and NSAIDs may influence the reaction of Alpha Gauss syndrome. So um this is the part that as we’re getting more cases, we’re learning more and more about the disease.

Alli 7:47

Are there patients that might have Alpha Gauss syndrome but not even know it?

NOURIAN 7:52

Yeah, absolutely. I think I think there was one study I remember reading that says it takes about a median of seven years until diagnosis for some patients. And for patients, especially with you know small, like you know, subclinical symptoms, they may kind of just constantly have, hey, I have an upset stomach, never really made the distinction. This is all this is directly related to bread meat products, or let’s just say a patient who comes in with a large allergy list and you know that you know, for drug classes that don’t necessarily make sense, and it’s like, oh, maybe these drug classes all share inactive ingredients that, oh, these were made from, you know, mammalian meat products.

Alli 8:28

That’s really interesting. And I kind of had this like thought that alpha gas syndrome was different than other food allergies, but I didn’t realize that it was because of the carbohydrate versus protein difference there. And so, and that is really interesting. And I that delay in symptoms must be really tricky then to navigate for patients too, where they just can’t figure out why they’re not feeling well because of there’s just so much time has elapsed.

NOURIAN 8:53

Absolutely. And I think part of the reason for the delay of diagnosis is just awareness about this. And so um, you know, I have to give a lot of kudos to patient-centered alpha gal groups who are really trying to raise awareness um, you know, at the local and national levels, just to get primary care physicians in rural areas, urban areas, everywhere, just to think, hey, maybe I should think about this on my differential when I have a patient come in with kind of vague symptoms.

Alli 9:20

Well, and we want anesthesia professionals to have this on their differential as well. So, how can anesthesia professionals identify patients with Alpha Gauss syndrome? Are there certain questions that we have to ask during the preoperative interview so that we don’t miss this? Any testing that patients need to have or follow-up questions that we need to ask?

NOURIAN 9:41

Yeah, sure. I think um, I think especially in endemic areas where, you know, you know, Tennessee, Virginia, southeast part of the United States, uh, I think it’s important for all providers to be aware of this, you know, particularly anesthesia providers, and maybe questions beyond just like, do you have any drug allergies? Things like, have you ever been diagnosed with alpha gal syndrome? Have you ever had any, you know, difficulty breathing or you know, GI symptoms several hours after having like beef, pork, or lamb, or nighttime symptoms after that? Not that, you know, every patient you should ask, hey, have you ever had like a too recent tick bite? But I think there’s some clues in the electronic medical record that may make you think, okay, like let me just ask this patient about this. So if you see multiple allergies listed on your screen and you’re thinking, okay, like that doesn’t necessarily make sense. Maybe I should ask them, hey, have they ever been exposed, have they had any recent tick bites or they have they ever been diagnosed with alpha gal syndrome? And kind of goes a little bit more into you know the perioperative management, but you know, hey, do you have any medications that just don’t agree with you? Um and does it matter by the brand of medication you take? Maybe one brand agrees with them. And then that kind of is a clue that maybe there’s something that is an inactive ingredient that that’s kind of going on from there.

Alli 10:57

Those are some really great questions that we can add to our preoperative interview. Do you think you mentioned the electronic medical record? So should this, should Alpha Gauss syndrome, should this be listed under the patient’s allergies or their medical problems or both? Where do we classify this?

NOURIAN 11:12

Ideally, I think it’d be my recommendation is to put it on both, uh, just so that way providers are a little bit more aware about this. And all providers, I mean nursing, pharmacy, you know, surgery, anyone who’s involved with taking care of this patient. Um, and I think ideally the terminology should be moved towards not red meat allergy, more toward towards, hey, this patient has alpha gal syndrome, just so that way you can really kind of understand this patient’s, you know, possible triggers and understand, hey, if there’s any medications we necessarily need to avoid. But I think the electronic medical record, you know, is a useful tool in the sense because it can help screen and even maybe now in the day of AI, maybe suggestions, hey, this patient may have alpha gal syndrome, please investigate into this a little bit more.

Alli 11:58

Interestingly, I think if you label something red meat allergy, it’s so easy for healthcare professionals to just say, oh, well, we’ll just keep red meat away from the patient without having that full understanding of what alpha Gauss syndrome is. So it makes sense to really label it correctly, Alpha Gauss syndrome. And that way we can help prevent all those additional exposures as well.

NOURIAN 12:23

Absolutely. That’s a fantastic point. Just because, you know, people think, okay, this is an outpatient thing. I don’t need to worry about this for surgery. You know, it’s they’re not gonna eat any of that here. You know, it’s just like, oh, they whatever. But, you know, we all learn in the anesthesia world that, you know, a patient has avocado allergies, maybe some other food allergies, hey, maybe this is associated with latex. You know, these are the things that we should, you know, kind of stepping up a little bit beyond. Uh, and again, to your point, that’s why I think it’s important to label it as alpha Gauss syndrome.

Alli 12:51

All right. And speaking of exposures, so once we make it into the perioperative environment and the operating room with a patient who has alpha Gal syndrome, what are the exposure risks in this environment?

NOURIAN 13:05

Sure. I think um it’s kind of important to divide up the exposure risks into, you know, forms of administration. And so you have medications that could be administered intravenously by the anaesthesiologist or nursing staff. There’s certain topical surgical products that you know the surgeon could implant or you know, place onto this patient. I’ll just kind of make a little side thing for that. You know, there’s also some medications that the patient may receive in the hospital postoperatively that potentially could be related to alpha Gall syndrome. And so talking about the medications that are given um intravenously, uh the one of the first main ones that you kind of think about is unfractionated heparin, basically made from pig intestines. And so potentially, you know, and I’ll talk a little bit more about heparin in, you know, in detail, but this could have a potential exposure, especially in you know, procedures in cardiovascular world, neurosurgical, neurosurgical world. And then in the world of you know, intravenous medications, uh, any sort of medication that’s been formulated with an active ingredient of glycerine, glycerol, gelatin, carragenin, there’s some loose data on magnesium, sterate, and steric acid. These are just things that potentially, I’m not saying 100%, but potentially could be a trigger for a patient with uh alpha gal syndrome. Moving on into, you know, surgical products, you know, a lot of the surgical foams and glues and matrices that they use to kind of help create uh hemostasis are typically gelatin-based and but could potentially be made from animal products. As to as far as something that is clearly an animal product, which is, you know, a bovine pericardium or uh, you know, a bioprosthetic valve that’s made from, you know, a you know, a pig valve, et cetera, like that. While it may be dematrices and gone through a process to remove some of the potential antigens, there still always is that theoretical risk that, you know, a patient with alpha gal syndrome uh could respond to these. And I think particularly in the patients in like the surgical oncology world, patients who are being exposed to biologics, alpha gal syndrome was found in patients with cetamat, for example, and that’s kind of where it was first described. So kind of thinking about patients who are receiving biologics in the alpha gal world, or for example, let’s just say a patient who for some reason needs pancreatic enzymes, you know, these are typically derived from animal products too. So it really does require quite a bit of homework before a patient comes into the operating room to create a safe, you know, perioperative home for this patient, um, just so that way they can move through without unintended consequences.

Alli 15:48

Well, and you mentioned heparin, and I’m a cardiac anesthetist, and this is something that is definitely cardiac anaesthetists need to have on their radar too. Let’s help our cardiac anesthesia professionals out. If you had a patient with known alpha gal syndrome coming to the operating room tomorrow for cardiac surgery on cardiopulmonary bypass, how would you prepare the patient and how would this impact your anaesthetic plan?

NOURIAN 16:16

Yeah, absolutely. I think that’s a great question. Um, I think I’ll first off say out by that just because the patient has alpha gal syndrome doesn’t mean that they automatically prohibit them from having heparin. There are many patients who have had cardiac surgery with heparin. Why heparin is very scary is that in, as we mentioned before, it’s made from porcine intestinal mucosa, but it’s given in very high doses in the uh cardiac operating room. If you get a situation where a patient has alpha gal syndrome and they have very severe symptoms of alpha gal syndrome, and they have or maybe a recent alpha IgE level to alpha gal that is very, very high, and you’re using high dose heparin, there’s the potential that this patient could have problems with heparin during this case. And those have been documented in the literature. And so I think having a conversation with the patient, conducting a thorough history of characterizing their alpha gal symptoms, had they ever been exposed to heparin in the past or had previous cardiac procedures and tolerated that would be the first step. If time permits, I would see if you could actually obtain a uh alpha gal-specific IgE levels prior to the surgery. And the reason I bring that up is that we’ve tried to create a protocol to risk stratify patients based off of Ig level and heparin exposure to kind of create like a heparin test to let’s just say help a patient out before you know going to the surgery. I would say next I would have a multidisciplinary discussion with the surgeon, with the perfusionist, pharmacy, hopefully get allergy immunology involved, potentially the blood bank is volved, um, because there are some known risks of alpha gal syndrome and blood transfusion. But just to get everybody aware on this plan that, you know, hey, it is potential this patient could have a reaction to heparin. And part of this plan, speaking with the surgeon, is that is there any sort of hemostatic products, thrombin gelatin agents, as I mentioned before, valves that we need to really consider before having this uh surgery, and uh, are there any alternatives to this? Um, if in this case this patient is having severe symptoms, have had ex has exposure to heparin in the past, had a reaction, had Ig levels, okay, well, we need to find some sort of alternative. You know, so kind of creating a different anticoagulation plan. So I think most perfusionists and cardiac anesthesiologists and surgeons are not really thrilled about the idea of doing cardiopulmonary bypass on the Bivalirudin or some of the other anticoagulation agents, but it is an option uh for a patient who isn’t deemed as a high-risk category. Lastly, I think it’s just also being prepared for any sort of uh anaphylaxis that could occur. So if you know it was deemed that, hey, this patient is going to proceed with heparin or we are gonna proceed with some sort of bioprosthetic valve, just being ready to maybe pre-medicate the patient for any sort of sensitivities or immune responses, and just being ready for any sort of anaphylaxis in the operating room. So all this, I think, yeah, while it may take time, I think it just the pre-meditation and discussions beforehand, I think would really pay off. And I believe is that anesthesiologists should be the leaders in this to help be the patient advocate and be the patient voice and helping the Alpha Gal patients safely.

Alli 19:38

With a lot of patient safety considerations, there’s a fund of knowledge about the syndrome or the medical problems. And then you mentioned things that we talk about all the time teamwork and communication, and then also collaborating with the patient too. And it seems like those are some of the key considerations for keeping our patients safe. Now, if we step outside the cardiac ORs and just back into that perioperative space, you mentioned a lot of ingredients in medications that may cause a reaction. So is there any way for anesthesia professionals to determine whether medications are safe for patients with alpha gal?

NOURIAN 20:21

Yes, there are ways to find whether a specific medication is safe for a patient with alpha gal syndrome. Unfortunately, there is no like master list that is distributed all over the world saying, you know, this one is good or this one is bad. And the reason that is, is because one might think propofol is propofol or midazolam is midazolam or oxycodone is oxycodone. However, those are all made by different manufacturers. Um, different hospitals have different contracts with different manufacturers. And let’s just say your hospital pharmacy system is ordering oxycodone from one manufacturer. And so it is possible to investigate whether this manufacturer used inactive ingredients that contain mammalian meat products to figure out whether that particular pill could be a trigger for a patient with Alpha Gauss syndrome. Unfortunately, sometimes even the same manufacturer may make changes lot to lot, and that becomes tricky into figuring out, and it requires a lot of investigational phone calls by either pharmacist to figure out exactly, you know, hey, how did you guys create this particular medication? And I’m creating a worst case scenario. Most times things are pretty stable as things kind of go on, but these are some of the homework pieces that, you know, if you have time to do, one can, you know, do ahead of time to help out. But the easiest way I would currently is to uh take a look at the medication. There should be a uh NDC number uh listed on every single medication. You can enter that into a government website called Daily Med, and that is it will live. All the inactive ingredients. And so this is not a for sure way, but is definitely a starting point to figuring out, okay, is this medication list any of the known kind of inactive ingredients that I mentioned above? And if it does, then I think it’s a conversation to be like, hey, pharmacist, can you look into this a little bit more to see, you know, is this safe for use? And so unfortunately, daily med is not 100% accurate. There are some different groups that are looking into fully identifying whether manufacturers are reporting all their medications uh correctly. And so Pill Clarity is a group that I find useful. And so they can do queries for patients actually. So if a patient with Alpha Gauss syndrome says, Hey, I went to the hospital, here’s a list of the medications and pictures of the medications they’re prescribing me to go home with, typically they’ll do a you know a query for that patient. You know, this group is also kind of starting to partner with different uh hospitals, kind of do all the queries for them for patients with Alpha Gauss syndrome. Unfortunately, the way the current landscape sits is that there is no FDA mandate to necessarily list whether inactive ingredients have animal products or not. And so that’s something that’s in the works, hopefully, through legislature, is to illuminate that just so that way at least it gives a starting point for pharmacists and for patients and for providers, their healthcare professionals, so that way they can uh help better take care of their patients.

Alli 23:27

Wow. Well, it seems like a lot of work is being done in the background. And we’ll include that link to Daily Med in the show notes as well, because it sounds like a good starting place. What are the potential reactions that patients might have to a medication that we give sometime in the perioperative period? And what can we do for treatment? What kind of time frame are we talking about? What can you tell us so that we can be prepared to treat patients if they have a reaction?

NOURIAN 23:56

Yeah, if a patient has you know mild alpha gal syndrome, what you may see is potential GI symptoms or uh rash and everything like that, anywhere from you know, maybe a couple hours after administration. Um, typically eating a red meat product will cause a reaction three to six hours after. However, administering a medication IV actually may speed things up a little bit. So you may see a little bit of a um a quicker response. However, under anesthesia, some of these skin findings may be hidden, but you know, it’s being aware of any sort of anaphylactic like symptoms, bronchospasm, rising airway pressures, uh, unexplained hypotension or azoplesia uh during the medication, uh during you know the anesthetic. And so really what you’re trying to do is, well, if at all possible, try to stop and remove any sort of exposing agent, you know, kind of quickly going through like, you know, what’s been given, what’s been going on, and then having everything ready to help prepare for anaphylaxis, epinephrine, 100% oxygen, vaso pressure support if needed, and then kind of like how you do for any sort of you know, major anaphylaxis, obtaining a tryptase level, steroids, H2 blockers, etc. As kind of alluded to before, if you’ve already screened your medications, you know, one of the things you can do in the operating room is kind of create like an alpha gal safe bag. Hey, these are medications that we’ve screened pre-screened, these are the you know, the things that we have ready to go. If you’re handing off the case to another, you know, healthcare professional, hey, please don’t reach inside the drug card and grab whatever to treat the patient. Please stick to this bag, keep this bag with this patient, and then having a plan for this patient in the post-operative period to only receive certain, let’s just say, pain medications like oxycodone that have been pre-approved by the pharmacist.

Alli 25:42

That is really helpful advice. So could you describe a practical perioperative plan for patients with alpha gal? Maybe just briefly going through pre-op, interop, and post-op considerations. Uh, just the high yield points.

NOURIAN 25:58

Have a conversation early with patients. Make sure alpha gal syndrome is listed in their medical record. Have a communication before the operation with the surgery team, perioperative clinic, and nurses and pharmacists. Understand this patient’s symptomology of alpha gal syndrome and if they’ve had any previous reactions. Prepare a list of medications to the best of your knowledge and reduce exposures and be prepared for any sort of anaphylaxis that could occur intraoperatively.

Alli 26:27

That was great. I particularly like the idea of the alpha gal safe bag because I think that is just allows anesthesia professionals to take good safe care of patients without that added stress of every time they open the anesthesia drawer saying, Oh, wait, can I give this medication? I’m not sure. You’ve kind of taken that thought process and done it before the patient gets to the operating room and allows like us to just keep patients safe without that extra stress level. All right. So let’s switch gears a little bit and talk about what patients need to know. So if a patient with Alpha GAU is scheduled for surgery, is there anything that they need to do before they even come to the hospital? How can they best be prepared? Um, and thinking along the lines of maybe like a patient checklist or questions that the patients need to be prepared to ask as well.

NOURIAN 27:21

And currently working on a pamphlet for patients to be able to hand to their providers and kind of go through the same sort of checklist and, you know, hopefully having that prime time uh in the next couple of months. But like with any sort of rare disease, a lot of times the patient unfortunately has to become the advocate for themselves in the healthcare system and dispel any sort of myths. You know, maybe there’s some people who don’t believe in Alpha Gauss syndrome and don’t even know anything about it. And so part of that has to do with kind of educating your team a little bit about what this is and how to, you know, and giving them the resources to look it up. But I would say make sure that Alpha Gauss syndrome is listed on your medical record. Tell your surgeon, your anesthesia team, anybody that’s involved, bring the list of your current medications and medications that have worked for you and medications that have not worked for you uh in the past. Ideally make an appointment with uh an allergist, or if you do have an allergist, make sure that this allergist is well known to your perioperative team. And then ask your provider, you know, will you guys be using heparin or gelatin or any sort of animal tissue in this uh operation? If so, do you guys have any alternatives available for this? And then asking your provider, hey, well, you know, what sort of symptoms should I look out for when I go home? Um, and when do I need to come back in? I guess, you know, maybe just a sentence that, you know, a per, you know, a patient could say to the you know, patients is like, hey, I have alpha gal syndrome, and you know, I may have reactions to medic medicines or medical products that are made for mammals. Have my medications or implants or surgical supplies been checked? And just having that conversation before going into the war, I think, will be helpful.

Alli 28:54

That’s great. And it’s like a mini spoiler review for your upcoming pamphlet. So that’s something that we’ll have to be on the lookout for too. All right, we have a new segment for our interview show today. Uh, I actually don’t think we’ve tried this yet for one of our guests on the Anesthesia Patient Safety podcast. So this one is a rapid-fire myth busting segment. Uh, don’t worry, I gave out these questions in advance. But can you give us a quick true or false to the following statements? If I don’t eat red meat, I’m safe from alpha-gal exposure.

NOURIAN 29:30

That is false. So avoiding red meat reduces one important aspect of exposure, but there still could be hidden ingredients and all sorts of medications and other products or beauty products, etc.

Alli 29:42

If a medication doesn’t contain pork or beef as the active ingredient, it’s safe.

NOURIAN 29:48

That is also false. Inactive ingredients may be relevant and they can vary from manufacturer to manufacturer. And one quote I remember reading was that 75% of all medications contain some level of animal-derived ingredients. Maybe not mammal, but animal-derived ingredients.

Alli 30:03

If the patient has alpha gal syndrome, we cannot use heparin.

NOURIAN 30:08

That is also false. Uh heparin is not automatically contraindicated in patients. Many patients may tolerate it, but high dose intravenous exposure, you know, particularly for cardiopulmonary bypass, maybe warrants uh a risk assessment or multidisciplinary planning.

Alli 30:23

Every patient with alpha gal needs every medication checked individually.

NOURIAN 30:29

This is mostly important in the perioperative setting. And so it’s important to have high-risk exact formulations uh for medications screened out beforehand.

Alli 30:41

An alpha gal IgE level tells us exactly how severe a patient’s reaction will be.

NOURIAN 30:47

This is also false. I would say that it can help contribute to risk assessment, but it’s not necessarily an accurate predictor of if you know if high, then the patient will have a surreal reaction. And if low, then the patient is completely safe.

Alli 31:01

Intravenous medications are always safer than oral medications.

NOURIAN 31:06

It’s actually quite the opposite. So I think intravenous medications will cross faster and have a more profound um immune response.

Alli 31:13

All right. Well done with that segment. That was a lot of good information in a short period of time. For anesthesia professionals who’ve not had a lot of experience providing anesthesia care for patients with alpha gout in the past. What advice do you have for them and any really important considerations for their practice?

 

NOURIAN 31:34

Sure. I’ll try to break this out into five points. I would say first, recognize the phenotype of uh this patient, the history of their exposures, you know, gastrointestinal systems, gelatin sensitivity, tick exposure, et cetera. I’m just really trying to do an accurate history for this patient. Second, I would say don’t assume that red meat allergy is just limited to food. Um, you know, relevant exposure could be a medication, heparin, gelatin, biologic implant that we talked about before. Three, check the exact formulation of the medication, drug names or drugs that, you know, just because the drug is named the same thing, and you know, manufacturers could be different. Um, there is no sort of static list that uh has all the list of you know alpha-gal unsafe medications. So really try to check the exact formulation or reach out to help for them. Fourth, I would say it’s important to make a multidisciplinary process out of this. Um, so safe care happens with everybody on board, anesthesia surgery, pharmacy, nursing, allergy immunology, and sometimes even the you know, blood bank or perfusionist in those cases. And then lastly, be prepared to treat for anaphylaxis, how you would do with any other sort of anesthetic case and you know, be very thoughtful about trying to minimize exposures.

Alli 32:46

That was great. And we will have this list in the show notes as well. So you can check that out. Thank you so much for sharing your expertise in this area. Is there anything else that you want to share that we haven’t talked about or something that we missed today?

NOURIAN 33:02

I would just say in like a positive note, I think there’s a lot more hope and great things coming out. They’re, you know, trying to work on like a first FDA-approved medication for actually just specifically for Alpha Gal patients. There’s some, you know, new research on creating uh knockout pigs that are Alpha Gal safe, you know, that you know potentially could help with in terms of help address this whole idea of you know deriving heparin from those pigs or deriving valve from those pigs. And I think that this is getting a lot more traction and exposure. Articles are coming out in the New York Times and you know, various other sort of uh mainstream media sites, which actually just kind of also help the cause of the you know raising awareness. So I do think that things are on the horizon and things are working forward. And you know, we gotta do the best we can to take care of these for these patients.

Alli 33:51

Well, it sounds like we’ll have to have you back on the show for an update in a few years, too.

NOURIAN 33:55

Sounds good. Thank you so much.

Alli 33:58

One more thing before we go. What’s next for your research and projects?

NOURIAN 34:03

As I alluded to, trying to make this pamphlet um and making this pamphlet twofold. One for patients to take to their providers, um, and then one for specifically anesthesia and surgery providers, just to, you know, have a quick reference and a starting point to help understand for this. And then ideally I’m trying to work on a multidisciplinary team to help kind of create like a consensus statement of you know alpha-gal surgery and in cardiac surgery, just to kind of compile together all the evidence that’s out there to really kind of help practitioners really decide exactly how to help death screen for patients.

Alli 34:39

Well, that’s really exciting. Good luck with these projects. And thank you so much for joining us on the show today.

NOURIAN 34:45

Yeah, thank you so much, Alli.

[Bechtel] Thank you so much to Dr. Nourian for joining us on the show today. And now you all have some homework to do. We hope that you will check out the all new APSF Newsletter Article, “Alpha-Gal Syndrome and Perioperative Patient Safety: Practical Considerations for Anesthesia Professionals” written by Govind Rangrass, MD, FASA; Karolina Brook, MD, FASA, CPPS; Maziar M. Nourian, MD; Rachel C. Wolfe, PharmD, MHA, BCCCP, FCCP. It was published online September 30^th and you can find the link in the show notes.

If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

If you can, we would love for you to subscribe to the podcast and maybe share it with a friend or a colleague or anyone you know who is interested in anesthesia patient safety. This way you can stay up to date with the latest in anesthesia patient safety, like learning about the perioperative considerations for patients with alpha-gal syndrome, and more. Thanks so much for listening.

Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.

© 2026, The Anesthesia Patient Safety Foundation