Sulfites asthmatic reactions

Severe, life-threatening asthmatic reactions following consumption of restaurant meals and wine have occurred secondary to ingestion of the food preservative potassium metabisulfite. Sulfites have been used for centuries as preservatives in wine and food. As antioxidants, they prevent fermentation of wine and discoloration of fruits and vegeta-... 

The fermentation process can be artificially controlled and impeded by the addition of sulfur dioxide or potassium metabisulfite. The addition of this preservative poses a potential health hazard. The residual sulfites present in wine have been known to elicit urticaria, asthmatic reactions and respiratory failure. In the United States, since 1987, warning labels indicating the presence of sulfites must appear on wine bottles containing at least 10 ppm of sulfites (Fisher 1997)- In addition to their importance in wine making, sulfur dioxide and sulfites are used as food additives for their antimicrobial effect. Contact dermatitis to potassium metabisulfite has developed in a pharmaceutical worker (Nater 1968) and may also occur in bakers, from occupational exposure to flour (Apetato and Marques 1986), and in hairdressers to permanent wave solution, but has not been reported in winemakers. Sulfur dioxide has also been reported to cause contact urticaria (Maibach and Johnson 1975). 

Adverse reactions to sulfites appear to occur mainly among a small percentage of asthmatics, but it is possible for individuals without asthma to be sulfite sensitive. It is typically more of a problem in individuals with severe asthma who are also taking corticosteroid drugs to control their disease. Among these individuals, the prevalence of sulfite sensitivity is about 8%, while it is about 1% in asthmatics who are not dependent on steroids (Taylor and Bush, 1986). 

The mechanism of sulfite-induced asthma is not well-understood. Reactions to sulfited foods probably depend on the sulfite residue level in the food, the sensitivity threshold of the individual, the type of food consumed, and whether sulfite exists in the free (more toxic) form or combined (less toxic) form. The toxicology of sulfites has been reviewed by Madhavi and Salunkhe (1995). Sulfite sensitivity is not a true allergic reaction (Taylor et al., 1988). The FDA initially estimated that more than 1 million Americans are sensitive to sulfites, but more recent estimates lowered the number of asthmatics who may be sulfite sensitive to 80,000-100,000 (Bush et al., 1986). 

Sulfite sensitivity Some of these products contain sulfites that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes. Sulfite sensitivity is seen more frequently in asthmatic or atopic nonasthmatic persons. 

Sulfites Preservative Antioxidants used to reduce spoilage can produce allergic reactions, especially in asthmatics... 

Allergic-type reactions, including anaphylaxis and life-threatening asthmatic exacerbation, may occur in patients with sulfite sensitivity. 

Sulfite sensitivity primarily affects a relatively small subgroup of asthmatic population (Bosso and Simon 2008), Salicylates can also cause allergenic hypersensitivity reactions (Sainte-Laudy 2001). 

The major symptoms of an adverse reaction to a sulfite are flushing, acute bronchospasm, and hypotension (SED-11, 492) (SEDA-10, 232) (SEDA-11, 221) (5). The incidence of sulfite sensitivity in an asthmatic population is estimated at about 10%. Sulfites have therefore been withdrawn from the composition of several medicines intended for asthmatic patients. 

Although it is extensively used in a variety of preparations, sodium metabisulfite and other sulfites have been associated with a number of severe to fatal adverse reactions. " These are usually hypersensitivity-type reactions and include bronch-ospasm and anaphylaxis. Allergy to sulfite antioxidants is estimated to occur in 5-10% of asthmatics, although adverse reactions may also occur in nonasthmatics with no history of allergy. 

Three different mechanisms have been proposed to explain the reaction to sulfites in asthmatic patients. The first is explained by the inhalation of sulfur dioxide, which produces bronchoconstriction in aU asthmatics through direct stimulation of afferent parasympathetic irritant receptors. Furthermore, inhalation of atropine or the ingestion of doxepin protects sulfite-sensitive patients from reacting to the ingestion of sulfites. The second theory, IgE-mediated reaction, is supported by reported cases of sulfite-sensitive anaphylaxis reaction in patients with positive sulfite skin test. Finally, a reduced concentration of sulfite oxidase enzyme (the enzyme that catalyzes oxidation of sulfites to sulfates) compared with normal individuals has been demonstrated in a group of sulfite-sensitive asthmatics. 

SC, sulfite, bisulfite, metabisulfite), which inhibit PPO and may combine with quinones or reduce quinones to phenols, thereby preventing pigment formation (4, 9-10). Sulfites can produce acute allergic reactions in some asthmatics, however, with serious if not lethal consequences (11-12). Therefore, the Food and Drug Administration has banned the use of sulfites in fruits and vegetables served or sold raw to consumers (13) and has proposed restrictions on the use of sulfites in certain fresh potato products (14). 

B. The formulation contains sodium metabisulfite as a preservative, which can cause acute allergic-like reactions in patients (especially asthmatics) who are sensitive to sulfites. 

Some patients appear to react to ingested metabisulfite rather than inhaled gas. There are several case reports of patients who experienced severe anaphylaxis-like reactions after eating sulfite-containing restaurant meals and whose symptoms have been reproduced by oral bisulfite provocation (Prenner and Stevens, 1976 Stevenson and Simon, 1981 Schartz, 1983). Interestingly, some patients give histories of pollution-related asthmatic exacerbations. 

Hydrocodone bitartrate is absolutely contraindicated in patients with known hypersensitivity reactions to hydrocodone. Commercial preparations may also contain sulfite compounds that can produce allergic reactions, including bronchospasm and anaphylaxis, in certain susceptible individuals, particularly asthmatic patients. In addition, the dye tartrazine is present in one preparation of hydrocodone bitartrate, combined with chlorpheniramine maleate and phenylephrine hydrochloride, that is used as an antitussive and expectorant agent (Vanex). Also known as FD C yellow No. 5, tartrazine can cause asthmatic and other allergic reactions in some susceptible patients, especially those with aspirin sensitivities. 

Other antioxidants include sulfites, often added to wine and fruits as a preservative and antibrowning agent, and EDTA, which immobilizes metal ions that often catalyze oxidation reactions. The presence of sulfites in foods is usually labeled because some people (especially asthmatics) are allergic to them. 

Several different intolerance reactions like urticaria, asthmatic attacks and induction of allergies and pseudo-allergic reaction in humans are known (Tsevat, 1987 Acosta, 1989 Simon, 1993). Sulfites irritate the skin and mucous membranes (Wuthrich, 1993). 

Bisulfites are oxidised in the body by sulfite oxidase (sulfite ferricytochrom c oxidoreductase) to sulfates, which are excreted in the urine. The enzyme activity is individual, and toxic effects of sulfur dioxide and sulfites are therefore variable. Some individuals tolerate amounts of up to 50 mg/kg, while in sensitive individuals such concentrations will cause headaches, nausea and diarrhoea. In asthmatics receiving steroids, sulfites may cause allergic reactions (ADI = 0.7 mg/kg bodyweight). 

In 1973, allergic reactions to sulfites were proven to exist. They occur at very low ingested concentrations (around 1 mg) and primarily concern asthmatics (4-10% of the human population). Asthmatics are therefore urged to abstain from drinking wine. Although SO2 sensitivity has not been clearly demonstrated for non-asthmatics, these allergic reactions led the US FDA (Food and Drug Administration) to require the mention of the... 

---