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Background and Importance Alpha-gal syndrome (AGS) is an IgE-mediated hypersensitivity reaction to the oligosaccharide galactose-α-1,3-galactose, typically acquired after tick bites. It is characterised by delayed allergic reactions (2–6 hours) after ingestion of mammalian meat or derived products, which may progress to anaphylaxis. In the hospital setting, AGS poses an additional challenge because many drugs and excipients (eg, gelatin, lactose, magnesium stearate, glycerol) are of animal origin. Published evidence is scarce and mainly limited to case reports, which increases uncertainty when managing surgical procedures.Aim and Objectives We report the case of a 58-year-old male, diagnosed with AGS in 2010 after multiple allergic reactions to tick bites and red meat ingestion. His home medication included simvastatin, omeprazole, bromazepam and an emergency epinephrine autoinjector. He tolerated some animal-derived excipients such as lactose and magnesium stearate. He was scheduled to undergo mechanical aortic valve replacement.Material and Methods The anesthesiology team requested a comprehensive perioperative medication review by the hospital pharmacy service. A total of 65 medications (anaesthetics, antibiotics, analgesics, anticoagulants, supportive therapies) were screened for potentially unsafe excipients using manufacturer data and excipient databases, verifying hospital-available specialties as excipients may vary among formulations. A premedication protocol with intravenous hydrocortisone and dexchlorpheniramine was established. Heparin safety was assessed with a provocation test prior to surgery, which was well tolerated, although alpha-gal contamination may vary between batches.Results During surgery, the patient received hydrocortisone, a heparin test dose, and subsequent full heparinisation with the same batch. Perioperative treatment included drugs previously determined to be safe: cefazolin, tranexamic acid, dexmedetomidine, opioids, benzodiazepines and others. The surgical procedure was performed without complications. Postoperatively, anticoagulation was initiated with fondaparinux (synthetic agent) as bridging therapy, followed by acenocoumarol containing magnesium stearate, which was accepted based on prior tolerance.Conclusion and Relevance This case illustrates the critical role of hospital pharmacists in ensuring safe drug use in AGS, where published evidence remains very limited. Assessment of active ingredients and excipients, consideration of individual tolerance and close multidisciplinary collaboration allowed a safe perioperative course. The development of standardised protocols for the management of AGS patients is essential to enhance patient safety and provide guidance for future clinical practice.Conflict of Interest No conflict of interest