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Hyperacidity: Oral: OTC labeling: Liquid (aluminum hydroxide 200 mg and magnesium hydroxide 200 mg per 5 mL): 10-20 mL 4 times/day (maximum:80 mL/day) Suspension (aluminum hydroxide 500 mg and magnesium hydroxide 500 mg per 5 mL): 10-20 mL 4 times/day, between meals and at bedtime (maximum: 45 mL/day) Tablet (aluminum hydroxide 300 mg and magnesium hydroxide 150 mg): 1-2 tablets after meals or at bedtime, or as needed (maximum: 16 tablets/day) Dosing: Pediatric (For additional information see "Aluminum hydroxide and magnesium hydroxide: Pediatric drug information" )

Hyperacidity: Oral: OTC labeling: Children ≥12 years: Refer to adult dosing. Dosing: Geriatric Refer to adult dosing. Dosing: Renal Impairment Aluminum and/or magnesium may accumulate in severe renal impairment. Dosage Forms: U.S. Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product Liquid, oral: Mag-Al: Aluminum hydroxide 200 mg and magnesium hydroxide 200 mg per 5 mL (30 mL) [dye free, ethanol free, sugar free; contains propylene glycol, sodium 4 mg/5 mL; peppermint flavor] Suspension, oral: Mag-Al Ultimate: Aluminum hydroxide 500 mg and magnesium hydroxide 500 mg per 5 mL (20 mL) [contains propylene glycol, sodium 4 mg/5 mL; peppermint flavor] Tablet, chewable: Alamag: Aluminum hydroxide 300 mg and magnesium hydroxide 150 mg [contains phenylalanine 2.63 mg; wild cherry flavor] Generic Equivalent Available: U.S. No Administration Liquid, suspension: Shake well before use; administer 1-3 hours after meals when stomach acidity is highest Tablet: Chew tablet thoroughly before swallowing or allow tablets to dissolve slowly in mouth. Follow with a full glass of water. Use Antacid for symptoms related to hyperacidity associated with heartburn, hiatal hernia, upset stomach, peptic ulcer, peptic esophagitis, or gastritis Adverse Reactions Significant Frequency not defined. Gastrointestinal: Constipation, chalky taste, cramping, fecal discoloration (white speckles), fecal impaction, nausea, vomiting Endocrine & metabolic: Hypophosphatemia (rare), hypermagnesemia (rare) Warnings/Precautions

Concerns related to adverse effects: • Hypophosphatemia: Prolonged antacid therapy may result in hypophosphatemia; aluminum in antacid may form insoluble complexes with phosphate leading to decreased phosphate absorption in the GI tract. Rarely, severe hypophosphatemia can lead to anorexia, muscle weakness, malaise, and osteomalacia.

Disease-related concerns: • Renal impairment: Use with caution in patients with renal impairment; avoid use in severe renal impairment; hypermagnesemia or aluminum intoxication may occur in severe renal impairment, particularly with prolonged use. Aluminum intoxication may lead to osteomalacia or dialysis encephalopathy.

Other warnings/precautions: • Self-medication (OTC use): Patients with renal disease or on a magnesium-restricted diet should consult a healthcare provider prior to use. Unless directed by a physician, do not use for >2 weeks or exceed the recommended daily dose. Metabolism/Transport Effects None known. Drug Interactions (For additional information: Launch Lexi-Interact™ Drug Interactions Program ) ACE Inhibitors: Antacids may decrease the serum concentration of ACE Inhibitors. Management: Separate fosinopril administration from antacids by at least 2 hours. US and Canadian recommendations for use of other ACE- inhibitors with antacids may vary. Consult appropriate labeling. Monitor for decreased therapeutic effects of ACE-inhibitors.

Exceptions: Enalaprilat; Ramipril. Risk D: Consider therapy modification Alfacalcidol: May increase the serum concentration of Magnesium Salts. Risk D: Consider therapy modification Allopurinol: Antacids may decrease the absorption of Allopurinol. Risk D: Consider therapy modification Alpha-/Beta-Agonists: Antacids may decrease the excretion of Alpha-/Beta-Agonists.

Exceptions: Dipivefrin. Risk C: Monitor therapy Amphetamines: Antacids may decrease the excretion of Amphetamines. Risk C: Monitor therapy Anticonvulsants (Hydantoin): Antacids may decrease the serum concentration of Anticonvulsants (Hydantoin). Risk C: Monitor therapy Antipsychotic Agents (Phenothiazines): Antacids may decrease the absorption of Antipsychotic Agents (Phenothiazines). Risk C: Monitor therapy Ascorbic Acid: May increase the absorption of Aluminum Hydroxide. Risk D: Consider therapy modification Atazanavir: Antacids may decrease the absorption of Atazanavir. Risk D: Consider therapy modification Bisacodyl: Antacids may diminish the therapeutic effect of Bisacodyl. Antacids may cause the delayed-release bisacodyl tablets to release drug prior to reaching the large intestine. Gastric irritation and/or cramps may occur. Risk D: Consider therapy modification Bisphosphonate Derivatives: Antacids may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of antacids containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate.

Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification Bisphosphonate Derivatives: Magnesium Salts may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral magnesium salts within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate.

Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification Bosutinib: Antacids may decrease the serum concentration of Bosutinib. Management: Administer antacids more than 2 hours before or after bosutinib. Risk D: Consider therapy modification Calcitriol: May increase the serum concentration of Magnesium Salts. Risk D: Consider therapy modification Calcium Channel Blockers: May enhance the adverse/toxic effect of Magnesium Salts. Magnesium Salts may enhance the hypotensive effect of Calcium Channel Blockers. Risk C: Monitor therapy Calcium Polystyrene Sulfonate: Laxatives may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. More specifically, concomitant use of calcium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of calcium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives or sorbitol. Risk X: Avoid combination Calcium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis and/or loss of efficacy of the cation exchange resin. Management: To minimize this interaction, consider: a)separating doses by 2 or more hours; b)rectal administration of the exchange resin; or c)alternatives to antacids. Monitor for metabolic alkalosis and attenuation of CPS effects. Avoid magnesium hydroxide. Risk D: Consider therapy modification Calcium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Risk D: Consider therapy modification

Calcium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Risk D: Consider therapy modification Cefditoren: Antacids may decrease the serum concentration of Cefditoren. Management: Concomitant use of cefditoren with antacids is not recommended. Consider alternative methods to control acid reflux (eg, diet modification) or alternative antimicrobial therapy. If antacid therapy can not be avoided, separate dosing by several hours. Risk D: Consider therapy modification Cefpodoxime: Antacids may decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy Cefuroxime: Antacids may decrease the serum concentration of Cefuroxime. Management: Consider administering antacids and cefuroxime at least 2 hours apart. Risk D: Consider therapy modification Chenodiol: Aluminum Hydroxide may decrease the serum concentration of Chenodiol. Management: Consider administration of chenodiol 2 hours before or 6 hours after aluminum-containing antacid products to prevent adsorption in the gastrointestinal tract. Risk D: Consider therapy modification Chloroquine: Antacids may decrease the serum concentration of Chloroquine. Management: Separate administration of antacids and chloroquine by at least 4 hours to minimize any potential negative impact of antacids on chloroquine bioavailability. Risk D: Consider therapy modification Citric Acid Derivatives: May increase the absorption of Aluminum Hydroxide. Risk D: Consider therapy modification Corticosteroids (Oral): Antacids may decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects. Risk D: Consider therapy modification

Corticosteroids (Oral): Antacids may decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects. Risk D: Consider therapy modification Dabigatran Etexilate: Antacids may decrease the serum concentration of Dabigatran Etexilate. Management: Dabigatran etexilate Canadian product labeling recommends avoiding concomitant use with antacids for 24 hours after surgery. In other situations, administer dabigatran etexilate 2 hours prior to antacids. Monitor clinical response to dabigatran therapy. Risk D: Consider therapy modification Dasatinib: Antacids may decrease the absorption of Dasatinib. Risk D: Consider therapy modification Deferasirox: Aluminum Hydroxide may diminish the therapeutic effect of Deferasirox. Risk X: Avoid combination Deferiprone: Antacids may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Risk D: Consider therapy modification Deferiprone: Magnesium Salts may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Risk D: Consider therapy modification Delavirdine: Antacids may decrease the serum concentration of Delavirdine. Management: Separate doses of delavirdine and antacids by at least 1 hour. Monitor for decreased delavirdine therapeutic effects with this combination. Risk D: Consider therapy modification Dexmethylphenidate: Antacids may increase the absorption of Dexmethylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Focalin XR brand), which could result in both increased absorption (early) and decreased delayed absorption. Risk C: Monitor therapy Eltrombopag: Aluminum Hydroxide may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., aluminum-containing products) by at least 4 hours. Risk D: Consider therapy modification

Dexmethylphenidate: Antacids may increase the absorption of Dexmethylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Focalin XR brand), which could result in both increased absorption (early) and decreased delayed absorption. Risk C: Monitor therapy Eltrombopag: Aluminum Hydroxide may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., aluminum-containing products) by at least 4 hours. Risk D: Consider therapy modification Eltrombopag: Magnesium Salts may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., magnesium-containing products) by at least 4 hours. Risk D: Consider therapy modification Elvitegravir: Antacids may decrease the serum concentration of Elvitegravir. Management: Separate administration of antacids and the elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate combination product by at least 2 hours in order to minimize the risk for an interaction. Risk D: Consider therapy modification Erlotinib: Antacids may decrease the serum concentration of Erlotinib. Management: Separate the administration of erlotinib and any antacid by several hours in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification Ethambutol: Aluminum Hydroxide may decrease the absorption of Ethambutol. Risk D: Consider therapy modification Fexofenadine: Antacids may decrease the serum concentration of Fexofenadine. Management: No specific recommendations concerning the time required between their administration are provided. Separate administration of each agent by as much time as possible to decrease the risk of an interaction. Risk D: Consider therapy modification Gabapentin: Antacids may decrease the serum concentration of Gabapentin. Management: Administer gabapentin at least 2 hours after antacid administration. Monitor patients closely for evidence of reduced response to gabapentin therapy when both of these drugs are being used. Risk D: Consider therapy modification HMG-CoA Reductase Inhibitors: Antacids may decrease the serum concentration of HMG-CoA Reductase Inhibitors. Risk C: Monitor therapy Iron Salts: Antacids may decrease the absorption of Iron Salts.

Exceptions: Ferric Gluconate; Ferumoxytol; Iron Dextran Complex; Iron Sucrose. Risk D: Consider therapy modification Isoniazid: Antacids may decrease the absorption of Isoniazid. Risk D: Consider therapy modification Itraconazole: Antacids may decrease the serum concentration of Itraconazole. Management: Administer itraconazole at least 1 hour after and 2 hours before administration of any antacids. Itraconazole oral suspension may be less sensitive to the effects of decreased gastric acidity. Risk D: Consider therapy modification Ketoconazole (Systemic): Antacids may decrease the serum concentration of Ketoconazole (Systemic). Management: Administer oral ketoconazole at least 2 hours prior to use of any antacid product. Monitor patients closely for signs of inadequate clinical response to ketoconazole. Risk D: Consider therapy modification Levothyroxine: Aluminum Hydroxide may decrease the serum concentration of Levothyroxine. Management: Separate administration of oral levothyroxine and aluminum hydroxide by at least 4 hours. Risk D: Consider therapy modification Mesalamine: Antacids may diminish the therapeutic effect of Mesalamine. Antacid-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Avoid concurrent administration of antacids with sustained-release mesalamine products. Separating antacid and mesalamine administration, and/or using lower antacid doses may be adequate means of avoiding this interaction. Risk D: Consider therapy modification Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Risk D: Consider therapy modification Methylphenidate: Antacids may increase the absorption of Methylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Ritalin LA brand), which could result in both increased absorption (early) and decreased delayed absorption. Risk C: Monitor therapy

Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Risk D: Consider therapy modification Methylphenidate: Antacids may increase the absorption of Methylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Ritalin LA brand), which could result in both increased absorption (early) and decreased delayed absorption. Risk C: Monitor therapy Misoprostol: Antacids may enhance the adverse/toxic effect of Misoprostol. More specifically, concomitant use with magnesium-containing antacids may increase the risk of diarrhea. Management: Avoid concomitant use of misoprostol and magnesium-containing antacids. In patients requiring antacid therapy, employ magnesium-free preparations. Monitor for increased adverse effects (e.g., diarrhea, dehydration). Risk D: Consider therapy modification Multivitamins/Minerals (with ADEK, Folate, Iron): May increase the serum concentration of Aluminum Hydroxide. Management: In patients with severe renal dysfunction, consider avoiding this combination of agents. Administering agents at least 2 hours apart may help minimize the interaction(s). Risk D: Consider therapy modification Multivitamins/Minerals (with ADEK, Folate, Iron): Antacids may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, antacids may decrease the absorption of orally administered iron. Management: Separate dosing of oral iron-containing multivitamin preparations and antacids by as much time as possible in order to minimize impact on therapeutic efficacy of the iron preparation. Risk D: Consider therapy modification Mycophenolate: Antacids may decrease the absorption of Mycophenolate. Management: Separate doses of mycophenolate and antacids by at least 2 hours. Monitor for reduced effects of mycophenolate if taken concomitant with antacids. Risk D: Consider therapy modification Mycophenolate: Magnesium Salts may decrease the serum concentration of Mycophenolate. Management: Separate doses of mycophenolate and oral magnesium salts. Monitor for reduced effects of mycophenolate if taken concomitant with oral magnesium salts. Risk D: Consider therapy modification Neuromuscular-Blocking Agents: Magnesium Salts may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Mycophenolate: Magnesium Salts may decrease the serum concentration of Mycophenolate. Management: Separate doses of mycophenolate and oral magnesium salts. Monitor for reduced effects of mycophenolate if taken concomitant with oral magnesium salts. Risk D: Consider therapy modification Neuromuscular-Blocking Agents: Magnesium Salts may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy Nilotinib: Antacids may decrease the serum concentration of Nilotinib. Management: Separate the administration of nilotinib and any antacid by several hours whenever possible in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification PenicillAMINE: Antacids may decrease the serum concentration of PenicillAMINE. Risk D: Consider therapy modification Phosphate Supplements: Antacids may decrease the absorption of Phosphate Supplements.

Exceptions: Potassium Phosphate. Risk D: Consider therapy modification Phosphate Supplements: Magnesium Salts may decrease the serum concentration of Phosphate Supplements. Management: Administer oral phosphate supplements at least 1 hour before, or 2 hours after, oral magnesium salt administration.

Exceptions: Potassium Phosphate. Risk D: Consider therapy modification Ponatinib: Antacids may decrease the serum concentration of Ponatinib. Risk X: Avoid combination Protease Inhibitors: Antacids may decrease the absorption of Protease Inhibitors.

Exceptions: Darunavir. Risk C: Monitor therapy QuiNIDine: Antacids may decrease the excretion of QuiNIDine. Risk C: Monitor therapy QuiNINE: Antacids may decrease the serum concentration of QuiNINE. Risk X: Avoid combination Quinolone Antibiotics: Antacids may decrease the absorption of Quinolone Antibiotics. Of concern only with oral administration of quinolones. Risk D: Consider therapy modification Quinolone Antibiotics: Magnesium Salts may decrease the absorption of Quinolone Antibiotics. Of concern only with oral administration of both agents. Risk D: Consider therapy modification Rilpivirine: Antacids may decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after rilpivirine. Risk D: Consider therapy modification Sodium Polystyrene Sulfonate: Laxatives may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of sodium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of sodium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives or sorbitol. Risk X: Avoid combination Sodium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis and/or loss of efficacy of the exchange resin. Management: To minimize this interaction, consider: a)separating doses by 2 or more hours; b)rectal administration of the exchange resin; or c)alternatives to antacids. Monitor for metabolic alkalosis and attenuation of SPS effects. Avoid magnesium hydroxide. Risk D: Consider therapy modification Sodium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Risk D: Consider therapy modification

Sodium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Risk D: Consider therapy modification Strontium Ranelate: Aluminum Hydroxide may decrease the serum concentration of Strontium Ranelate. Management: Separate administration of strontium ranelate and aluminum hydroxide by at least 2 hours whenever possible in order to minimize this interaction. Risk D: Consider therapy modification Strontium Ranelate: Magnesium Hydroxide may decrease the serum concentration of Strontium Ranelate. Management: Separate administration of strontium ranelate and magnesium hydroxide by at least 2 hours whenever possible in order to minimize this interaction. Risk D: Consider therapy modification Tetracycline Derivatives: Antacids may decrease the absorption of Tetracycline Derivatives. Risk D: Consider therapy modification Tetracycline Derivatives: Magnesium Salts may decrease the absorption of Tetracycline Derivatives. Only applicable to oral preparations of each agent. Risk D: Consider therapy modification Trientine: Antacids may decrease the absorption of Trientine. Management: Separate trientine dosing from other oral drugs (eg, antacids) by at least 1 hour. Monitor for decreased therapeutic effects of trientine if an antacid is initiated/dose increased, or increased effects if an antacid is discontinued/dose decreased. Risk D: Consider therapy modification Trientine: Magnesium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum concentration of Magnesium Salts. Risk D: Consider therapy modification Ursodiol: Aluminum Hydroxide may decrease the serum concentration of Ursodiol. Management: Consider administration of ursodiol 2 hours before or 6 hours after aluminum-containing antacid products to prevent adsorption in the gastrointestinal tract. Risk D: Consider therapy modification

Trientine: Magnesium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum concentration of Magnesium Salts. Risk D: Consider therapy modification Ursodiol: Aluminum Hydroxide may decrease the serum concentration of Ursodiol. Management: Consider administration of ursodiol 2 hours before or 6 hours after aluminum-containing antacid products to prevent adsorption in the gastrointestinal tract. Risk D: Consider therapy modification Vismodegib: Antacids may decrease the serum concentration of Vismodegib. Management: Carefully consider the need for any medication that increases the pH of the upper GI tract (PPIs, H2RAs, antacids), as these could significantly reduce vismodegib systemic exposure. Vismodegib dose increases are unlikely to compensate for this effect. Risk D: Consider therapy modification Vitamin D Analogs: May increase the serum concentration of Aluminum Hydroxide. Specifically, the absorption of aluminum may be increased, leading to increased serum aluminum concentrations. Risk X: Avoid combination Pregnancy Implications See individual agents. Breast-Feeding Considerations See individual agents. Dietary Considerations Should be taken 1-3 hours after meals. Some products may contain sodium and/or phenylalanine. Pricing: U.S. (Medi-Span®)

Concentrate (Maalox TC Oral) 600-300 mg/5 mL (30 mL): $0.53 International Brand Names Fanta (TW); Lederscan (HK); Maalox (AT, BB, BS, CZ, DE, FR, GB, GR, HN, IE, IL, IT, JM, NL, PE, PH, PY, TH, TT, UY); Maalox Plus (PE) Use of UpToDate is subject to the Subscription and License Agreement . Topic 8614 Version 42.0 © 2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.6- C21.56 Licensed to: AsanBook Dig. Med. Lib. | Support Tag: [1005-83.177.194.223-B60670ABF6-S244013.14]