Everyday Drugs

A guide to everyday drugs & alpha-gal syndrome (AGS)

AGS & medical products

Gelatin

Other inactive ingredients

Pancreatic Enzymes

Thyroid medications

Suppositories & vaginal capsules

IBS supplements

Conjugated estrogen

Vitamins

Lubricants

Topicals

Adhesive bandages

Alpha-gal syndrome and medical products

There are important medical uses of mammalian-sourced medications, treatments and devices that were not immediately apparent in the initial description of AGS as a delayed allergy to red meat.

Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Rev Clin Immunol. 2020;16(7):667-677.

The evidence for the presence of α-Gal in these different food and medical products varies markedly, with some items clearly expressing the oligosaccharide (e.g., cetuximab) and other products being labeled by some groups as “risky” seemingly only because there is some constituent that is derived from mammals (e.g., magnesium stearate, glycerin). Although in many cases the data is insufficient to make informed judgments, we think it is worthwhile to attempt to create a framework for thinking about relative risk and by extension management of the syndrome.

Platts-Mills TAE, Li RC, Keshavarz B, Smith AR, Wilson JM. Diagnosis and Management of Patients with the α-Gal Syndrome. J Allergy Clin Immunol Pract. 2020;8(1):15-23.e1.

Many drugs, vaccines, and other medical products contain mammalian ingredients. The risks associated with the use of medical products that contain mammal-derived ingredients are highly variable and poorly studied. Some, including certain biologics, should be avoided or used with caution. Others, such as tablets containing magnesium stearate or lactose, contain little to no alpha-gal and are tolerated by most people with AGS. 

There is no data on the risk of reaction associated with some products listed on this page. They are included because they are derived from mammals or contain ingredients derived from mammals. See the papers cited for more information.

It’s important to understand that sometimes the danger of not using a medical product outweighs the risk of a reaction (e.g., antivenom, rabies vaccine).

Click on the image below to enlarge

Gelatin capsules and gelcaps

Gelatin (a glycoprotein) typically comes from skin or hooves of hogs, horses, cows or other large mammals.

__________

Gelatin capsules (“gel-caps”) are used for many medicines and may give rise to symptoms in a small proportion of patients. This exposure has been an infrequent (<5%) source of heartburn and/or nausea in patients, especially those whose medication regimen make contain multiple gelatin-based capsules.

Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Rev Clin Immunol. 2020;16(7):667-677.

Gelatin based capsules are used for many medicines and may give rise to symptoms in a small proportion of patients. Certainly they can add confusion in cases where a mammal-free diet has not successfully controlled symptoms.

Platts-Mills TAE, Li RC, Keshavarz B, Smith AR, Wilson JM. Diagnosis and Management of Patients with the α-Gal Syndrome. J Allergy Clin Immunol Pract. 2020;8(1):15-23.e1.

Gelatin used in medical products is typically derived from pig or cow collagen and contains alpha-gal. Gelatin in gelatin capsules and gelcaps may give rise to reactions in some patients with AGS. Other everyday medical products that may contain gelatin/collagen include:

  • Gelatin capsules (6,57)
  • Gelcaps (6,57)
  • Gabapentin oral solution (6)
  • Lidocaine patch (6)
  • Gummy supplements (57)

Note that some vaccines and many perioperative medical products also contain gelatin/collagen and that parenterally administered gelatin is significantly riskier than oral consumption of gelatin.

Read more about medical products that contain gelatin on the Alpha-gal Information’s gelatin webpage.

 

Other inactive ingredients in pills, etc.

Lactose, magnesium stearate, glycerin, and more

For <10% of patients, the avoidance diet also includes removing dairy and derivatives as well as gelatin. In addition, multiple medications are derived from mammals and specific mammalian tissues are used as medical devices. Products such as heart valves, gelatin-based plasma expanders, and pancreatic enzymes, are sources of alpha-gal exposure yet may trigger a reaction in more select patient groups. In keeping with this, a minority of patients may benefit from avoiding a wide range of products that are prepared with mammalian-derived constituents.”

Lactose and magnesium stearate may contain alpha-gal but are frequently not an issue.

Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Rev Clin Immunol. 2020;16(7):667-677.

There have been rare reports of subjects with α-Gal syndrome who experienced reactions that were attributed to oral medications, even those that did not contain gelatin. Magnesium stearate, which can be sourced from mammalian fat (i.e., stearic acid), was described as a likely culprit in one such case. Given that magnesium stearate is not structurally similar to α-Gal, the implication was that residual α-Gal could be present as a contaminant in some preparations. 

Platts-Mills TAE, Li RC, Keshavarz B, Smith AR, Wilson JM. Diagnosis and Management of Patients with the α-Gal Syndrome. J Allergy Clin Immunol Pract. 2020;8(1):15-23.e1.

Lactose and lactose derivatives

Pharmaceutical grade lactose is produced by concentrating whey or permeate (a co-product of whey protein concentrate production) to over-saturate the lactose, then removing, refining, drying and milling the lactose crystals. Pharmaceutical grade lactose is produced to meet rigid specifications, such as specific form and size distribution, monohydrate, crystalline, 40 mesh to 325 mesh, and a spray-dried mixture of crystalline and amorphous lactose for all applications. All products meet the requirements of the U.S., European and Japanese Pharmacopeias.

Typical Composition
Lactose (minimum) 99.8%
Protein 0.01%
Fat 0%
Ash 0.03%
Moisture 4.5-5.5%
U.S. Dairy Export Council

Lactose is a sugar derived from whey (milk). It is used in over 20% of prescription drugs and about 6% in over-the-counter medicines. Unlike proteins and lipids, sugars are not glycosylated and therefore lactose itself is alpha-gal-free. However, while pharmaceutical-grade lactose is highly purified, it can be contaminated with trace amounts of whey protein, which, unlike lactose, is glycosylated with alpha-gal (cit#).

Most people with alpha-gal syndrome tolerate lactose in pills. However, some people do report reactions. Patients reacting to lactose in pills tend to have AGS complicated by MCAS, making it difficult to determine whether the reactions are AGS or MCAS-related.

There is no data on AGS-associated risks of lactose in medical products that are not delivered via the oral route. However, contamination of lactose with milk proteins has been identified in reports of inhaled corticosteroid product lot testing. There is one published report of a milk protein-related hypersensitivity reaction after inhalation of a lactose-containing dry powder inhaler (cit#). For these reasons, some patients who tolerate lactose in pills try to avoid inhalers and parenterally administered products that contain it, out of an abundance of caution.

Several other milk-derived ingredients are also found in drugs, including casamino acids, casein, and lactalbumin.

Select publications on lactose and milk protein allergy

Note that there is no literature on lactose and AGS, but whey (the milk protein that lactose is derived from) is glycosylated with alpha-gal.

 

Magnesium stearate

Magnesium stearate is a common inactive ingredient in tablets. Magnesium stearate can be derived from plants or animals. Research by a vegan group suggests that the vast majority of magnesium stearate in the U.S. is derived from plants (cit #), however pharmacists at VeganMed report that some medical products contain mammal-derived magnesium stearate (Sachin Shah, personal communication).

There is a lack of data on the alpha-gal content of magnesium stearate or its association with reactions.  Experts report that most people with AGS tolerate magnesium stearate in pills (6,57). However, there are anecdotal reports and at least one published report of a patient with alpha-gal syndrome reacting after taking medications containing magnesium stearate (38).

 

Select publications on magnesium stearate and AGS

Glycerin

Glycerin (glycerol, glycerine) is a viscous liquid that is widely used in both food and pharmaceutical products. Glycerin is common in both oral medications (typically suspensions) and parenterally administered medical products, such as propofol.

Like magnesium stearate, glycerin can be derived from plants or animals.

There is a lack of data on the alpha-gal content of magnesium stearate or its association with reactions.

Other inactive ingredients

In addition to the above, many perioperative, prescription, and OTC drugs contain other mammal-derived inactive ingredients (32,33,34,35,57). Some of these pose a known risk to people with AGS; others contain mammalian byproducts for which there is little to no data on alpha-gal content or their ability to contribute to clinical reactions.

From Ask Adina:

The following is an incomplete listing of common ingredients associated with mammalian-derived products listed in DailyMed and in the Ask Adina processor. Individual reactions and tolerance to listed ingredients may vary — consult with a pharmacist or other healthcare professional when making treatment decisions.

Alpha-gal Information cannot attest to the accuracy of this information, which was provided by a third party (Ask Adina). We recommend using it as a starting point and verifying all information independently. 

Plant or mammal-derived

Examples of ingredients that may be derived from mammals or plants
ingredients but share the same UNII. Verify ingredients source with the manufacturer.

  • Stearic acid: 4ELV7Z65AP (shares UNII with flax-derived ingredients)
  • Glyceryl tristearate: P6OCJ2551R (note that vegetable stearine, which is plant-derived, shares the same UNII)
  • Magnesium stearate: 70097M6I30 (often animal-derived)
  • Amino acids, essential: N7U7BXP2OI
  • Amino acids, unspecified: 0O72R8RF8A
  • Allantoin: 344S277G0Z (listed with urea, an animal product)
  • Cortisone: V27W9254FZ (derived from cholesterol, can be from animal or synthetic source)
  • Isopropyl Palmitate: 8CRQ2TH63M
  • Glycerin: PDC6A3C0OX (can be animal, plant-based, or synthetic)
  • Lactic acid, unspecified: 33X04XA5A

 

 

Bovine (derived from cows)

May include names such as cow, Bos taurus, beef, bovine

  • Heparin (Bovine): P776JQ4R2F
  • Heparin sodium (Bovine): 6DZH9J3B27
  • Gelatin (unspecified): 2G86QN327L
  • Gelatin Type B Bovine: WIL1404U79
  • Gelatin Type B Bovine: F5AJW0ONK4
  • Gelatin Type B Bovine: A7JR5F8DLH
  • Calfactant: Q4K217VGA9
  • Glucagon: 76LA80IG2G
  • Thrombin: 25ADE2236L
  • Thyrotropin Alfa: AVX3D5A4LM
  • Palmitostearic acid: Q8Y7S3B85M

In addition, check soap products for tallow

Porcine (pig-derived)

May be referred to as Pig, porcine, sus scrofa.

  • Heparin: T2410KM04A
  • Enoxaparin: E47C0NF7LV
  • Enoxaparin sodium: 8NZ41MIK1O
  • Pancrelipase amylase: YOJ58O116E
  • Pancrelipase lipase: 8MYC33932O
  • Pancrelipase protease: 3560D81V50
  • Glucagon: 76LA80IG2G
  • Heparin Sulfate: 47959853R5
  • Defibrotide free acid: 568FY5I1YI
  • Pepsin: GID333S43J
  • Gelatin (unspecified): 2G86QN327L
  • Gelatin type a porcine (160 bloom): 7Z075S9991
  • Gelatin hydrolysate (porcine skin, mw 3000): 0K9R94573C
  • Sodium chondroitin sulfate (porcine; 5500 mw): H5BJH23Z9A
  • Heparin sulfate (porcine 5500 mw): 47959853R5

Lanolin-derived (from sheep’s wool)

  • Lanolin (wool)
  • Lanolin: 7EV65EAW6H
  • Lanolin oil: OVV5IIJ58F
  • Hydroxylated lanolin: EOI0B9800C
  • peg-75 lanolin: 09179OX7TB
  • peg-60 lanolin: K2OI1D27ET
  • lanolin alcohols: 884C3FA9HE
  • acetylated lanolin alcohols: SNN716810P
  • peg-20 hydrogenated lanolin: 5PP3KJ4T6S
  • acetylated lanolin: 2X654GD19H
  • peg-40 hydrogenated lanolin: 959P5CXE48
  • lanolin acid: D1CZ545P7Z
  • peg-70 lanolin: 687SBQ855W
  • peg-10 lanolin: PLH8U521GH
  • ppg-12-peg-50 lanolin: QJP3Q6598J
  • acelytated lanolin: 2X654GD19H
  • hydroxylated lanolin: EOI0B9800C
  • peg-150 lanolin: 8WTH94XZF2

Derived from other mammals

  • Rabbit immunoserum and immunoglobulins, may be listed under Oryctolagus cuniculus.
  • Monoclonal antibodies (mAb, -mab) are derived from mice and associated with multiple deaths and life-threatening allergic reactions for populations with alpha-gal reactions
  • Anitvenin products for snake/scorpion bites are often derived from sheep (ovine) or
  • Horse (equine) sources

Milk-derived

Casein, whey, and lactose:

  • Casein: 48268V50D5
  • Hydrolyzed casein: M93H91U80R
  • Sodium caseinate: 7473P66J9E
  • Whey: 8617Z5FMF6
  • Lactoferrin, bovine: KG21X1090A
  • Lactulose: 9U7D5QH5AE
  • Lactic acid, dl-: 3B8D35Y7S4
  • Caprylic acid: OBL58JN025
  • Orotic acid: 61H4T033E5
  • Lactose, unspecified form: J2B2A4N98G
  • Lactose monohydrate: EWQ57Q8I5X
  • Anhydrous lactose: 3SY5LH9PMK
  • Lactulose: 9U7D5QH5AE
  • Lactitol: L2B0WJF7ZY
  • 4′-galactosyllactose: B8CW1B3F6R

Carrageenan-derived

Carrageenan is derived from red algae that, like non-primate mammals, glycosylate with alpha-gal. 

  • Chondrus crispus carrageenan: UE856F2T78
  • Carrageenan: 5C69YCD2YJ
  • Carrageenan calcium: 5C4SQ0541D
  • Chondrus crispus: OQS23HUA1X
  • Iota.-carrageenan: 3582R1F52W
  • Carrageenan sodium: 7CY8BVL34N

Source: Ask Adina

When in doubt, verify that drugs are mammal-free through VeganMed’s drug information service.

Carrageenan

Carrageenans are a family of linear sulfated polysaccharides that are extracted from a group of red algae (red seaweed) that make alpha-gal. Although carrageenans are not made from mammals, they contain the alpha-gal epitope (54,57). At least 1-2% of people with alpha-gal syndrome (AGS) report reacting to carrageenan (57). Patient advocates believe that the actual number is much higher.

Currently, we are not aware of any literature dealing with risks to people with AGS related to medical products containing carrageenan much less data that could be used to assess relative risks related to different forms and amounts of carrageenan in these products. However, given that some people with AGS report severe reactions to carrageenan in food, the risk cannot be ruled out. More research is needed.

Read more about medical products that contain carrageenan on Alpha-gal Information’s carrageenan webpage.

Pancreatic Enzymes

Pancreatic enzymes: The enzymes used for replacement of pancreatic function (e.g., pancrealipase) are purified from the pancreas of large mammals. These proteins, and other mammalian-derived enzymes, have been shown to elicit positive skin tests yet have been administered successfully in several patients. Alternatively, we have patients who were not diagnosed with AGS (due to their dietary choices) until beginning pancreatic enzymes, and this mammalian exposure produced symptoms (predominantly pruritus).

Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Rev Clin Immunol. 2020;16(7):667-677.

Enzyme replacement: The pancreatic enzymes which are used for replacement in some cases of cystic fibrosis or other causes of pancreatic failure are purified from the pancreas of large mammals. These proteins, and also other mammalian-derived enzymes, have been shown to express α-Gal and have functional activity in basophil activation tests.

Platts-Mills TAE, Li RC, Keshavarz B, Smith AR, Wilson JM. Diagnosis and Management of Patients with the α-Gal Syndrome. J Allergy Clin Immunol Pract. 2020;8(1):15-23.e1.

Pancreatic enzymes are derived from mammals and contain alpha-gal (126, 127, 128). However, some people with AGS tolerate these products or a subset of them (6,57,126, 127, 128).

Pancreatic enzymes that contain mammal-derived ingredients include, but are not limited to (6,36,57,103):

  • Viokase
  • Pertzye
  • Zenpep (Allergan)
  • Creon

Pancreatin (Now Foods, Bloomingdale, Ill) is an over-the-counter dietary aid (103) that also contains mammal-derived ingredients.

 

Select publications on pancreatic enzymes and AGS:

Thyroid medication

Thyroid hormones: Supplementation or replacement of endogenous thyroid hormone with ‘natural’ products (e.g., Armour thyroid) may be less ideal in patients with AGS since these products are derived from porcine thyroid glands. However, if patients feel strongly regarding this choice, we often supervise initial dosing in the clinic and only cease if symptoms develop (which we have seen happen both acutely as well as after several weeks of dosing). Of note, this issue – as well as that of pancreatic enzyme replacement and heart valves (see below) – may be solved by using alpha-gal deficient pigs as a source of material.

Commins SP. Diagnosis & management of alpha-gal syndrome: lessons from 2,500 patients. Expert Rev Clin Immunol. 2020;16(7):667-677.

Some medications used to treat hypothyroidism contain porcine thyroid extracts, for example Armour Thyroid (57,103). Products containing synthetic levothyroxine may be a suitable alternative for some patients.

If other mammal-derived ingredients, like gelatin (or potentially mammal-derived ingredients, like magnesium stearate) are a concern, alternatives include:

Note: manufacturers can change ingredients at any time. We cannot verify that these products are free of mammal-derived ingredients or other sources of alpha-gal. Contact the manufacturer or VeganMed for more information. 

Select publications on thyroid medication and alpha-gal syndrome:

Suppositories and vaginal capsules

The patient was a 65-year-old woman who had previously experienced 6 episodes of anaphylaxis after eating beef and pork during the previous 2 years. The workup performed at the time revealed positive skin prick test (SPT) results with a panel of commercially available food allergens including beef and pork (Bial-Arístegui) and cetuximab 5 mg/mL (Erbitux; Merck SL). sIgE to beef, pork, lamb, rabbit, chicken, cat dander, rFel d 1, and α-gal from bovine thyroglobulin (ImmunoCAP-250 analyzer, Thermo Fisher Scientific) yielded positive results with beef, pork, lamb, rabbit, cat dander, and α-gal from bovine thyroglobulin (12.4 kUA/L, 5.01 kUA/L, 6.3 kUA/L, 2.5 kUA/L, 0.54 kUA/L, and 52.3 kUA/L, respectively). The patient experienced no clinical problems by strictly following an avoidance diet excluding mammal meat until she was diagnosed with vaginitis. She was prescribed a fenticonazole vaginal capsule (Lomexin 600, Casen Recordati). Fifteen minutes after the application of the vaginal capsule, she experienced generalized erythema and intense pruritus quickly followed by hives, palpebral and labial angioedema, chest tightness, and dyspnea.

Vidal C, Méndez-Brea P, López-Freire S, González-Vidal T. Vaginal Capsules: An Unsuspected Probable Source of Exposure to α-Gal. J Investig Allergol Clin Immunol. 2016;26(6):388-389.

Some suppositories (28,87) and vaginal capsules (37) contain gelatin. There are reports of AGS patients reacting to these, including one published account of a severe reaction to a gelatin-containing vaginal capsule.

Select publications on suppositories and vaginal capsules and AGS

IBS supplements

Similar to previously reported studies, we show that alpha-gal continues to be present in Zenpep, Pancreatin, Armour Thyroid, and EnteraGam. Furthermore, these all interact with AGS serum and may lead to adverse reactions clinically. This is important because medications are harder to selectively avoid and symptoms may be inappropriately attributed to patients’ underlying medical issue (eg, pancreatitis, inflammatory bowel, or hypothyroid).

Kuravi KV, Sorrells LT, Nellis JR, et al. Allergic response to medical products in patients with alpha-gal syndrome. J Thorac Cardiovasc Surg. Published online April 9, 2021. doi:10.1016/j.jtcvs.2021.03.100

EnteraGam (Entera Health, Cary, NC), a bovine immunoglobulin and immunoprotein isolate for managing irritable bowel syndrome and inflammatory bowel disease, contains alpha-gal (103).

Estrogen Therapy

Some hormone replacement therapy products contain conjugated estrogen derived from horse urine, for example, Premarin and Prempro. There is a lack of data on the alpha-gal content of these products or their association with reactions.

Alternatives include products with synthetic estradiol.

Vitamins

Some vitamins are mammal-derived. There is a lack of data on the alpha-gal content of these products or their association with reactions, but there are anecdotal reports of reactions. Patients report that mammal-derived vitamin D3 is particularly problematic for them.

Alternatives include vegan vitamins. There is vegan vitamin D3 which is derived from lichens.

Lubricants

Some lubricants contain glycerin or gelatin. Glycerin can be derived from plants or mammals. There is a lack of data on the alpha-gal content of these products or their association with reactions, but there are anecdotal reports of reactions.

Alternatives include vegan, carrageenan-free lubricants.

Topicals

Some topical products contain lanolin or other mammal-derived ingredients. There is a lack of data on the alpha-gal content of these products or their association with reactions, but there are numerous anecdotal reports of reactions.

Alternatives include vegan, carrageenan-free products.

Topical antibiotics

According to the manufacturer, as of Mar 10, 2025, the following over-the-counter antibiotics do not contain animal-derived ingredients:

According to VeganMed, as of Mar 10, 2025, the following does not contain animal-derived ingredients;

Adhesive bandages and surgical tape

There are mammal-derived ingredients in the adhesive of many adhesive bandages.  There is a lack of data on the alpha-gal content of these products or their association with reactions, but there are numerous anecdotal reports of reactions.

Adhesive bandages

Alpha-gal-friendly alternatives include 3M Coban and animal-free adhesive bandages.

According to VeganMed and/or the manufacturer, the following products do not include animal-derived ingredients: 

Read more about adhesive bandages in this VeganMed article: Why Your Bandages Aren’t Vegan.