What is the recommended dosage and frequency of Maalox (aluminum hydroxide, magnesium hydroxide, simethicone) for an adult patient with heartburn, acid reflux, or upset stomach?

Maalox Dosing for Heartburn and Acid Reflux

Standard Dosing Regimen

For symptomatic relief of heartburn or acid reflux, take 2 teaspoonfuls of liquid Maalox 5-6 times daily after meals and at bedtime, followed by a sip of water if needed, with a maximum of 12 teaspoonfuls in 24 hours. 1

• Do not use the maximum dosage for more than 2 weeks without medical evaluation 1
• Shake the bottle well before each use 1

Clinical Context and Limitations

Antacids like Maalox provide rapid but short-lived symptom relief and should not be used as primary therapy for gastroesophageal reflux disease (GERD). 2, 3

Why PPIs Are Superior for GERD

• The American Gastroenterological Association recommends proton pump inhibitors (PPIs) as first-line therapy for GERD, as they are significantly more effective than antacids or H2-receptor antagonists for both symptom control and healing of esophagitis 2, 3
• Antacids work by directly neutralizing acid in the esophagus and provide relief within minutes, but their effect lasts only 30-70 minutes 4
• If you require Maalox more than twice weekly for heartburn, you should be evaluated for PPI therapy rather than continuing chronic antacid use 2, 3

Appropriate Use of Maalox

As-Needed Breakthrough Relief

• Maalox is most appropriately used for occasional breakthrough symptoms in patients already on acid suppression therapy 3
• The rapid onset of action makes it suitable for on-demand use when symptoms occur 2
• Alginate-containing antacids (like Gaviscon) may be preferable to standard antacids for post-prandial symptoms, as they neutralize the acid pocket that forms after meals 3

Timing Considerations

• Take after meals and at bedtime when acid exposure is highest 1
• Do not take Maalox simultaneously with fluoroquinolone antibiotics (like moxifloxacin or ciprofloxacin), as it reduces their absorption by approximately 60% 5
• If taking fluoroquinolones, separate Maalox by at least 2 hours after or 4 hours before the antibiotic dose 5

Critical Pitfalls to Avoid

• Do not use Maalox as monotherapy for chronic or frequent heartburn (more than twice weekly), as this indicates GERD requiring PPI therapy 2, 3
• Do not exceed 12 teaspoonfuls in 24 hours or continue maximum dosing beyond 2 weeks 1
• Do not assume that increasing antacid frequency will provide adequate control of GERD—this approach fails to address the underlying pathophysiology and delays appropriate treatment 2, 3
• If symptoms persist despite regular Maalox use, seek medical evaluation rather than continuing to self-treat, as this may indicate erosive esophagitis, Barrett's esophagus, or other complications requiring endoscopy 2, 3

When to Escalate Therapy

• Heartburn occurring more than twice weekly warrants a trial of once-daily PPI therapy taken 30 minutes before breakfast 3
• If once-daily PPI fails after 4-8 weeks, escalate to twice-daily dosing (before breakfast and dinner) rather than adding or continuing antacids 2, 3
• Persistent symptoms on twice-daily PPI therapy require endoscopy and possibly pH monitoring to confirm the diagnosis and guide further management 2, 3