Aluminum Hydroxide

Brand Names: Di-Gel, Maalox, Mylanta, Riopan, Rolaids

Clinical Names: Aluminum Hydroxide

Summary

generic name: Aluminum Hydroxide

trade names: Di-Gel®, Maalox®, Mylanta®, Riopan®, Rolaids®, etc.

type of drug: Antacid
Note: see "antacids" for information on other forms of antacids

used to treat: Heartburn, reflux esophagitis, gastritis, peptic ulcer; also used by people on dialysis or experiencing kidney failure to reduce phosphorus absorption and prevent hyperphosphatemia.

overview of interactions:
• adverse drug effects: Aluminum toxicity

• nutrient affected by drug: Vitamin B1 (Thiamine)

• nutrient affected by drug: Calcium and Calcium citrate

• nutrient adversely affected by drug: Phosphorus

• nutrient affecting drug toxicity: Citrus Juice

• nutrient affecting drug performance: Alginates




Interactions

adverse drug effects: Apart from its adverse nutritional side effects, aluminum is a toxic mineral and some degree of aluminum absorption from aluminum-containing antacids is unavoidable. (Anonymous. Nutr Rev 1980;38:242-243)

• nutritional concerns: Most nutritionally-oriented practitioners prescribe calcium- or magnesium-based antacids and discourage routine use of aluminum-containing antacids.

nutrient affected by drug: Vitamin B1 (Thiamine)

• mechanism: Aluminum-based antacids may lower Thiamine absorption.

• nutritional concerns: The adverse effect on absorption of Vitamin B1 can be reduced by not taking such antacids with meals or supplements.

nutrient affected by drug: Calcium and Calcium citrate

• mechanism: Aluminum-based antacids can complex with phosphates to cause a depletion of calcium stores. Aluminum hydroxide causes increased loss of calcium through urine and stool.
(Spencer, H, Kramer L. Arch Intern Med 1983;143:657-658).

• mechanism: Calcium citrate has been found to act in a manner similar to citrus juice to significantly increase aluminum absorption from antacids.
(Walker JA, et al. Arch Intern Med 1990;150:2037-2039; Weberg R, Berstad A. Eur J Clin Invest 1986 Oct;16(5):428-432; Nolan CR, et al. Kidney Int 1990;38:937-941.)

• nutritional concern: Individuals taking aluminum-based antacids should avoid using calcium citrate at the same time. Nolan et al found that doses of 950 mg of calcium citrate can significantly elevate aluminum levels in the body. The risks of an adverse reaction between calcium citrate and aluminum-containing compounds are especially high for individuals with kidney failure, particularly those on dialysis.
(Nolan CR, et al. Kidney Int 1990;38:937-941; Walker JA, et al. Arch Intern Med 1990;150:2037-2039.)

nutrient adversely affected by drug: Phosphorus

• mechanism: Aluminum binds dietary phosphate. Depletion of phosphorus may occur as a result of consuming aluminum hydroxide.

• nutritional concerns: Extended or repeated use of aluminum hydroxide in people with normal kidney function can deplete phosphorus to unacceptably low levels. However, for those on dialysis or with kidney failure, the drug's effect of reducing phosphorus absorption is beneficial; as their tendency toward excessive phosphorus levels can be dangerous. Anyone choosing to use aluminum-containing antacids on a regular basis would be well advised to discuss the issue of phosphorus depletion with their healthcare provider, pharmacist, or both.

nutrient affecting drug toxicity: Citrus Juice

• mechanism: Consumption of citrus juice substantially enhances aluminum absorption from antacids. The consumption of calcium citrate acts according to the same mechanism to increase aluminum absorption, as discussed above.

• research: Research done at the Institute of Food Research found that urinary aluminum increased by a factor of 10 in 24 hours when Aludrox, an aluminum antacid, and orange juice were ingested together.
(Fairweather-Tait S, et al. Eur J Clin Nutr 1994 Jan;48(1):71-73.)

• nutritional concerns: Citric acid containing substances, particularly citrus juice and calcium citrate, should not be taken with aluminum antacids. Consumption of 7-10 ounces of orange juice, in combination with an aluminum-based antacid, could be adequate to induce absorption of unhealthy levels of aluminum.

nutrient affecting drug performance: Alginates, a thick gel, containing alginic acid, derived from algae

• mechanism: Research indicates that alginate gel physically blocks stomach acid from contacting the esophagus.

• research: The use of this gel in conjunction with aluminum-based antacids offers a potentially superior method of treating heartburn. Researchers found that this combination of the alginate and antacid was more effective at relieving symptoms and improving healing than was the antacid alone.
(Maxton DG, et al. Br J Clin Pract. 1988 Sep;42(9):368-371; McHardy O. South Med J 1978;71 (suppl 1):16-21; Graham DY, et al. Curr Ther Res 1977,22:653-658.)

• nutritional synergy: The studies cited suggest that two tablets of alginate, containing 200 mg alginic acid, should be chewed before each meal and at bedtime.


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Do not rely solely on the information in this article.

The information presented in Interactions is for informational and educational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, case reports, and/or traditional usage with sources as cited in each topic. The results reported may not necessarily occur in all individuals and different individuals with the same medical conditions with the same symptoms will often require differing treatments. For many of the conditions discussed, treatment with conventional medical therapies, including prescription drugs or over-the-counter medications, is also available. Consult your physician, an appropriately trained healthcare practitioner, and/or pharmacist for any health concern or medical problem before using any herbal products or nutritional supplements or before making any changes in prescribed medications and/or before attempting to independently treat a medical condition using supplements, herbs, remedies, or other forms of self-care.



References

Anonymous. Is aluminum harmless? Nutr Rev 1980;38:242-243. (Review)

Coburn JW, Mischel MG, Goodman WG, Salusky IB. Calcium citrate markedly enhances aluminum absorption from aluminum hydroxide. Am J Kidney Dis. 1991 Jun;17(6):708-711.
Abstract: The effect of calcium citrate on intestinal aluminum absorption, assessed by the increment in urinary aluminum excretion, was evaluated in eight normal men. Baseline urinary aluminum excretion was determined for 2 days; thereafter, subjects ingested aluminum hydroxide for 3 days. In a cross-over study, subjects were given either calcium citrate, 950 mg four times a day, or placebo during the 3 days of aluminum hydroxide ingestion (2.4 g/d). Plasma aluminum levels were measured on the second control day and the third day of aluminum hydroxide ingestion. Baseline urinary aluminum excretion was 0.02 +/- 0.004 (6.5 +/- 1.1 micrograms/g creatinine) and 0.03 +/- 0.005 mumol/mmol creatinine (7.4 +/- 1.3 micrograms/g creatinine). These values increased during aluminum hydroxide therapy, but values were much greater when calcium citrate was ingested with aluminum hydroxide. On 3 consecutive days, urinary aluminum excretion levels were 11.1 +/- 3.23, 8.8 +/- 2.9, and 5.3 +/- 0.7 times greater during the administration of calcium citrate with aluminum hydroxide than with aluminum hydroxide alone. Plasma aluminum levels did not differ in the two treatment groups. Thus, calcium citrate markedly enhances the absorption of aluminum from aluminum hydroxide and the two must not be prescribed together in patients with renal failure.

Fairweather-Tait S, Hickson K, McGaw B, Reid M. Orange juice enhances aluminium absorption from antacid preparation. Eur J Clin Nutr 1994 Jan;48(1):71-73.
Abstract: Aluminium absorption from four doses of the antacid preparation 'Aludrox' when taken alone, with orange juice or with milk was compared by measuring the change in urinary aluminium following Aludrox dosage in 15 normal adults. There was an approximately 10-fold increase in 24 h urinary aluminium excretion following the Aludrox plus orange juice (232 micrograms) which was significantly higher than that following Aludrox alone (62 micrograms) (P < 0.001), but milk had no effect on aluminium absorption. The results showed that orange juice greatly enhanced aluminium absorption and should not therefore be taken in conjunction with aluminium-containing antacid preparations.

Gaby AR. Aluminum: The ubiquitous poison. Nutr Healing 1997;4:3,4,11.

Graham DY, Lanza F, Dorsch ER. Symptomatic reflux esophagitis: A double-blind controlled comparison of antacids and alginate. Curr Ther Res 1977,22:653-658.

Lindberg JS, Copley JB, Koenig KG, Cushner HM. Effect of citrate on serum aluminum concentrations in hemodialysis patients: a prospective study. South Med J. 1993 Dec;86(12):1385-1388.
Abstract: Twenty hemodialysis patients were prospectively evaluated to determine if concomitant citrate and aluminum administration enhances the absorption of aluminum, thereby increasing the possibility of toxicity. The four-phase study consisted of phase I, a washout phase; phase II, an aluminum treatment phase; phase III, a treatment phase combining aluminum and soluble calcium citrate; and phase IV, a treatment phase with the patient's original prestudy phosphate binder. Results disclosed a progressive rise in serum aluminum levels (microgram/L) from 47 +/- 8 (phase I) to 62 +/- 12 (phase II) to 74 +/- 13 (phase III) and a drop to 58 +/- 12 (phase IV). The difference in levels between phases I and III was significant. Additionally, and despite the fact that serum calcium concentrations did not change, serum phosphate and immunoreactive parathyroid hormone concentrations were significantly lower when aluminum and citrate were used together. This suggests that citrate enhances the absorption of aluminum and therefore increases the possibility of toxicity in the patient with end-stage renal disease.

Maxton DG, Miller JP, Whorwell PJ, Butler JK. A study of Algicon, an antacid-alginate preparation, in patients with reflux oesophagitis. Br J Clin Pract. 1988 Sep;42(9):368-371.

McHardy O. A multicentric, randomized clinical trial of Gaviscon in reflux esophagitis. South Med J 1978 Jan;71 Suppl 1:16-21.
Abstract: Gaviscon tablets and the standard antacid proved equally effective in reducing the number of heartburn attacks. Chi-square tests revealed no significant difference between the two treatment groups at the end of weeks 1, 2, 3, or 4. Heartburn score was arrived at by multiplying heartburn incidence by heartburn severity. This heartburn score also indicated no significant difference between the two treatment groups at the end of the four weeks. Tabulation of the mean number of tablets consumed by patients in the two groups was made. There was no significant difference between the two groups in tablet consumption, indicating equal demand as well as equal compliance in the two groups. Esophagoscopy done before and after 28 days of treatment showed that Gaviscon and the standard antacid tablets were equally effective in each group. There was significant, and equal, decrease in the severity in the specific signs of esophagitis, friability, erosion, and ulceration in both treatment groups, as well as in such nonspecific signs as hyperemia, edema, and exudate. The validity and clinical acceptance of an alginic acid-containing agent, Gaviscon, which through a foaming action delivers a minimal dose of antacid directly at the site of acid irritation of the esophageal mucosa, has been confirmed in a multicentric, well-controlled randomized clinical trial.

Nolan CR, DeGoes JJ, Alfrey AC. Aluminum and lead absorption from dietary sources in women ingesting calcium citrate. South Med J. 1994 Sep;87(9):894-898.
Abstract: Animal models suggest that citrate-containing compounds augment absorption of aluminum from food and tap water, causing aluminum accumulation in bone and brain despite normal renal function. Citrate also enhances lead absorption in animals. We questioned whether use of calcium citrate by women as a calcium supplement causes an increase in aluminum or lead absorption from dietary sources. Changes in 24-hour urine aluminum and lead excretion, plasma aluminum level, and whole blood lead level were assessed in 30 healthy women before and during treatment with calcium citrate (800 mg of elemental calcium per day). During calcium citrate therapy, urinary aluminum excretion and plasma aluminum level increased significantly. In contrast, there were no changes in urine or whole blood lead levels. We conclude that treatment with calcium citrate significantly increases absorption of aluminum from dietary sources. Additional studies are needed to determine whether long-term use of calcium citrate leads to aluminum accumulation and toxicity.

Nolan CR, Califano JR, Butzin CA. Influence of calcium acetate or calcium citrate on intestinal aluminum absorption. Kidney Int. 1990 Nov;38(5):937-941.
Abstract: The risk of aluminum (Al) accumulation in patients with chronic renal failure has led to use of non-Al phosphate binders. Frequently, Al and non-Al phosphate binders are co-administered. Unfortunately, calcium citrate (Ca citr), when given with Al-gel, markedly enhances Al absorption. To determine whether calcium acetate (Ca acetate) also augments Al absorption, 10 normal volunteers were each given orally, three-day courses of the following drug combinations dosed four times daily: 1) aluminum hydroxide gel (Al[OH]3) (5 ml) alone; 2) Al[OH]3 (5 ml) plus Ca acetate (1330 mg); 3) Al[OH]3 (5 ml) plus Ca citr (950 mg). A nine day wash-out occurred between each course. Al levels were measured using flameless atomic absorption spectrophotometry. Daily urine Al excretion was measured during a two-day baseline before each course and during each three-day drug course. Plasma Al was obtained during each baseline and drug course. Mean 24-hour Al excretion (micrograms/g creatinine/day) at baseline versus treatment for each combination was: 1) 5.9 +/- 3.2 versus 42.0 +/- 40.7 (mean +/- SD); 2) 5.7 +/- 3.0 versus 40.3 +/- 28.6: 3) 6.3 +/- 3.4 versus 175.8 +/- 103.3. Al excretion was significantly greater with combination 3 than with either 1 or 2 (P less than 0.05). The difference between 1 and 2 was not significant. Plasma Al (micrograms/liter) at baseline versus treatment for each combination was: 1) 5.3 +/- 4.2 versus 8.1 +/- 2.5 (mean +/- SD); 2) 3.1 +/- 2.2 versus 7.3 +/- 2.9; 3) 3.0 +/- 2.3 versus 12.0 +/- 6.1.

Sakhaee K, Ruml L, Padalino P, Haynes S, Pak CY. The lack of influence of long-term potassium citrate and calcium citrate treatment in total body aluminum burden in patients with functioning kidneys. J Am Coll Nutr. 1996 Feb;15(1):102-106.
Abstract: BACKGROUND: It has been suggested that citrate salts might enhance aluminum (Al) absorption from a normal diet, posing a threat of Al toxicity even in subjects with normal renal function. We have recently reported that in normal subjects and patients with moderate renal failure, short-term treatment with tricalcium dicitrate (Ca3Cit2) does not significantly change urinary and serum Al levels. However, we have not assessed total body Al stores in patients on long-term citrate treatment. OBJECTIVE: The objective of this study was to ascertain body content of Al non-invasively using the increment in serum and urinary Al following the intravenous administration of deferoxamine (DFO) in patients with kidney stones and osteoporotic women undergoing long-term treatment with potassium citrate (K3Cit) or Ca3Cit2, respectively. METHODS: Ten patients with calcium nephrolithiasis and five with osteoporosis who were maintained on potassium citrate (40 mEq/day or more) or calcium citrate 800 mg calcium/day (40 mEq citrate) for 2 to 8 years, respectively, and 16 normal volunteers without a history of regular aluminum-containing antacid use participated in the study. All participants completed the 8 days of study, during which they were maintained on their regular home diet. Urinary Al excretion was measured during a two-day baseline before (Days 5, 6) and for 1 day (Day 7) immediately following a single intravenous dose of DFO (40 mg/kg). Blood for Al was obtained before DFO administration, and at 2, 5 and 24 hours following the start of the infusion. RESULTS: The median 24-hour urinary Al excretion (microgram/day) at baseline versus post-DFO value was 15.9 vs. 44.4 in the normal subjects and 13.3 vs. 35.7 in the patients. These values were all within normal limits and did not change significantly following DFO infusion (p = 0.003 and p = 0.0001, respectively). The median change of 17.1 micrograms/day in urinary Al in the normal subjects was not significantly different from the 18.7 micrograms/day change measured in the patient group (p = 0.30). Similarly, no change in the mean serum Al was detected at any time following the DFO infusion, either in the patient or control group (patients 4.1 to 4.3 ng/ml, controls 7.4 to 4.6 ng/ml). CONCLUSION: The results suggest that abnormal total body retention of Al does not occur during long-term citrate treatment in patients with functioning kidneys.

Spencer H, Kramer L. Antacid-induced calcium loss. Arch Intern Med 1983;143:657-658. (Editorial)

Walker JA, Sherman RA, Cody RP. The effect of oral bases on enteral aluminum absorption. Arch Intern Med 1990 Oct;150(10):2037-2039.
Abstract: Physicochemical considerations suggest that citrate may potentiate gastrointestinal aluminum absorption via the formation of an aluminum citrate moiety. We tested this hypothesis and also studied whether sodium bicarbonate would have a similar effect. Eight healthy adults each partook of four oral regimens: aluminum alone, aluminum plus sodium bicarbonate, aluminum plus citrate (as Shohl's solution), and citrate alone. Twenty-four hour urine collections were obtained immediately preceding and during the second day of each medication period for determination of aluminum content. A significant but similar increment in urinary aluminum occurred with both aluminum alone and aluminum plus sodium bicarbonate, while only a small increment was noted with Shohl's solution alone. The rise in urinary aluminum obtained with aluminum plus Shohl's solution, however, was nearly eight times that seen with either aluminum alone or aluminum plus sodium bicarbonate (327 micrograms vs 45 micrograms and 41 micrograms, respectively). Citrate thus appears to augment gastrointestinal aluminum absorption markedly, an effect not shared by an equivalent dose of sodium bicarbonate. Citrate administration to patients with renal failure who are also taking aluminum-containing medication may be harmful.

Weberg R, Berstad A. Gastrointestinal absorption of aluminum from single doses of aluminum containing antacids in man. Eur J Clin Invest 1986 Oct;16(5):428-432.
Abstract: Ten subjects with normal renal function were given different single doses of aluminium containing antacids (1, 4, or 8 tablets). The antacid tablets (aluminium content 244 mg tablet-1) were chewed and swallowed either with water, with orange juice, or with citric acid solution. There was a marked increase in serum concentration of aluminium when the antacids was ingested with citric acid (P less than 0.001) or with orange juice (P less than 0.05). When antacids were taken with water, a slight, but significant increase in serum aluminium concentration was seen with 4, but not with 1 or with 8 tablets. Following all doses of antacid, a significant increase in 24 h urinary excretion of aluminium was seen. The estimated absorption of aluminium was 8 and 50 times higher when antacids were taken with orange juice or with citric acid, respectively, than when taken with water. Thus, measurable quantities of aluminium are absorbed from single oral doses of antacids. The absorption is substantially enhanced by concomitant ingestion of citric acid.