Maalox Dosing with Concurrent PPI Therapy
For adults with GERD taking a PPI, use Maalox (aluminum hydroxide/magnesium hydroxide) at 10-15 mL (2-3 teaspoonfuls) as needed for breakthrough symptoms, up to 5-6 times daily after meals and at bedtime, not exceeding 60 mL (12 teaspoonfuls) in 24 hours. 1
Primary Recommendation for Breakthrough Symptoms
Alginate-containing antacids are the preferred first-line PRN option for breakthrough GERD symptoms despite morning PPI therapy, as they provide the most rapid symptom relief and are particularly effective for post-prandial and nighttime symptoms. 2
Standard antacids like Maalox (aluminum hydroxide) are the most rapidly acting agents available for immediate symptom control and can be combined with PPIs to sustain their rapid-acting effect. 2
Standard Maalox Dosing
The FDA-approved dosing for aluminum hydroxide is 2 teaspoonfuls (10 mL) taken 5-6 times daily after meals and at bedtime, followed by a sip of water if needed. 1
Maximum dose: Do not exceed 12 teaspoonfuls (60 mL) in 24 hours, and do not use maximum dosage for more than 2 weeks. 1
Each 5 mL teaspoonful contains 320 mg of aluminum hydroxide as the active ingredient. 1
Before Adding Antacids: Optimize Your PPI First
Ensure the morning PPI is taken correctly—30-60 minutes before the first meal of the day—to optimize effectiveness. 2
If breakthrough symptoms persist on once-daily PPI, escalate to twice-daily PPI dosing before adding other medications, as twice-daily PPI is superior to once-daily for gastric acid suppression and symptom control. 3, 2
Standard PPI dosing for GERD is omeprazole 20-40 mg once or twice daily, lansoprazole 30 mg daily, or equivalent agents for 4-8 weeks. 3
Personalized Adjunctive Therapy Based on Symptom Pattern
Use alginate-containing antacids for breakthrough symptoms and post-prandial symptoms. 2
Use nighttime H2-receptor antagonists (such as famotidine) for nocturnal symptoms when used as-needed. 2
Use baclofen for regurgitation or belch-predominant symptoms. 2
Critical Pitfalls to Avoid
Do not add a nocturnal H2RA to twice-daily PPI therapy, as there is no evidence of improved efficacy with this combination. 2
Avoid metoclopramide due to unfavorable risk-benefit profile. 2
Remember that H2RA efficacy diminishes with regular use due to tachyphylaxis. 2
Do not use maximum antacid dosage for more than 2 weeks without medical evaluation. 1