When do we prescribe antacid suspensions, such as aluminum hydroxide (Aluminum Hydroxide) or magnesium hydroxide (Magnesium Hydroxide), to patients, particularly pediatric or geriatric patients, with symptoms of acid reflux, heartburn, and dyspepsia?

When to Prescribe Antacid Suspensions

Antacid suspensions (aluminum hydroxide, magnesium hydroxide) should be prescribed as adjunctive therapy for breakthrough symptoms in patients with confirmed GERD who are already on optimized PPI therapy, particularly for post-prandial or nighttime symptoms, and in patients with known hiatal hernia. 1

Primary Indications for Antacid Suspensions

Adults with GERD

Antacid suspensions, particularly alginate-containing formulations, are indicated for breakthrough symptoms in patients already on acid suppression therapy. 1 The AGA guidelines specifically recommend alginate antacids for:

• Breakthrough symptoms despite optimized PPI therapy 1
• Post-prandial symptoms (after meals) 1
• Nighttime symptoms as an adjunct to H2-receptor antagonists 1
• Patients with documented hiatal hernia where alginates neutralize the post-prandial acid pocket 1

Antacids should NOT be used as monotherapy for confirmed GERD requiring long-term management. 1 PPIs remain the mainstay of therapy for acid suppression, with antacids serving only as adjunctive agents. 1, 2

Pediatric Patients

Antacid suspensions should NOT be routinely prescribed for infants and young children. 1, 3

Critical pediatric contraindications include:

• Infants with uncomplicated gastroesophageal reflux (GER) - the "happy spitter" who is growing well 1, 3
• Infants presenting with brief resolved unexplained events (BRUEs) 1
• Simple spitting up or throat-clearing that is not troublesome 1, 3
• Irritability alone without confirmed GERD 3

The AAP emphasizes that acid suppression therapy (including antacids) exposes infants to increased risks of pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis in preterm infants. 1, 3

First-line management in pediatrics must be lifestyle modifications: 1, 3, 4

• Smaller, more frequent feedings 1, 3, 4
• Thickened formula (for formula-fed infants without milk-protein intolerance) 1, 4
• Upright positioning after feeds 1
• Avoiding overfeeding and frequent burping 1

Antacids may only be considered in pediatric patients with:

• Confirmed GERD with troublesome symptoms or complications (erosive esophagitis, failure to thrive, feeding refusal) 3
• Documented erosive esophagitis on endoscopy 1, 3

Even in these cases, PPIs (particularly omeprazole) are preferred over antacids for pediatric GERD requiring pharmacotherapy. 2

Geriatric Considerations

In elderly patients with dysphagia from chronic GERD and erosive esophagitis, oral disintegrating formulations may be preferred over traditional antacid suspensions. 5 However, the same principles apply: antacids serve as adjunctive therapy for breakthrough symptoms, not primary treatment. 1

Monitor elderly patients for:

• Drug interactions - antacids can alter absorption of many medications by changing gastric pH, adsorption, or chelation 6
• Electrolyte disturbances with prolonged use, particularly in patients with chronic renal failure 6
• Constipation with aluminum-containing products 7, 6
• Diarrhea with magnesium-containing products 6

Dosing and Administration

For adults, magnesium hydroxide suspension is dosed at 30-60 mL once daily (preferably at bedtime) or in divided doses, with a full glass of water. 8 Duration should not exceed 2 weeks without physician evaluation. 7

Critical Pitfalls to Avoid

Do not prescribe antacids as empiric long-term therapy without objective confirmation of GERD diagnosis. 1 If symptoms persist beyond 4-8 weeks of PPI therapy, perform endoscopy and prolonged wireless pH monitoring off medication to confirm GERD before escalating therapy. 1, 2

Do not use antacids as monotherapy for confirmed GERD requiring maintenance treatment. 1, 9 PPIs provide significantly faster and more complete symptomatic relief and healing compared to antacids alone. 9

Avoid prescribing any acid suppression (including antacids) for normal infant regurgitation. 1, 3 GER occurs in more than two-thirds of infants and is typically self-limited. 3

Schedule other medications appropriately to avoid drug interactions - most interactions can be avoided by separating administration times. 7, 6

When Antacids Are Appropriate as Self-Medication

Antacids are appropriate for self-medication in:

• Episodic or food-related heartburn in patients without confirmed GERD 9
• Minor episodes of heartburn not requiring chronic management 6
• Non-ulcer dyspepsia with intermittent symptoms 6, 9

However, patients should seek medical evaluation if symptoms persist beyond 2 weeks or worsen. 7, 9