ACIDITY and REMEDY

Continuing from my previous post, i'll be discussing about medicines that can be helpful in reducing excessive stomach acid. In previous post, we've known about natural remedies for acidity. Now, let us know about medicines that can be used for the treatment of this problem. 

To treat Acidity, Several categories of drugs can be used. Such as- 

1. Antacids

2. H2 Blocker

3. Proton pump Inhibitor

4. Prostaglandins

Let us know each category individually. What does each category mean?, what drugs fall into each category?, how do they help in reducing stomach acid? and in what other conditions we can use them?, what're the side effects? and when we shouldn't take these?, what are the precaution to take with these drugs? etc etc. 

Let us start with Antacids.....

⏩ Antacids: 

Simply the word Antacid tells us what this can mean, if we break the word into two parts like Anti-acid.Agents that work against acid we can call them antacid in a very simpler way. 

 Antacids are a class of drugs used to treat conditions caused by the acid that is produced by the stomach. For better understanding who missed my previous post, the stomach naturally secretes an acid called hydrochloric acid that helps to break down foods. When acid secretion is active in stomach, the contents of the stomach becomes acidic in nature with a pH level of 2 or 3. pH levels are a measure of acidity in the stomach: the lower the number, the greater the acidity.

 The stomach, duodenum, and esophagus are protected from acid by several protective mechanisms. When there is too much acid or protective mechanisms are inadequate, the lining of the stomach, duodenum or esophagus may become damaged by the acid, giving rise to inflammation and ulceration and their various gastrointestinal symptoms such as nausea, abdominal pain, and heartburn (due to gastroesophageal reflux disease or GERD). In conditions like this, antacids can be used. They come as a liquid or chewable tablets and can be bought from pharmacies and shops without a prescription which is known as OTC or Over The Counter drug.

➦Common types of Antacids 

 Antacids in common use salts of magnesium, aluminium and calcium. Some mixtures contain sodium and should be used with caution in patients who should avoid excess sodium intake.

Many different types of antacid are available. Some are sold under a brand name and others are named after their main ingredient.

They can be divided as systemic (i.e., sodium salts), non-systemic (calcium, magnesium and aluminum salts), and complex antacids . Most prescribed antacids contain a mixture of aluminum and magnesium salts. 

➤ Systemic Antacids

The term Systemic means affecting the entire body, rather than a single organ or body part. 

They are soluble, readily absorbed and capable of changing the pH of extracellular fluid. These are useful in case of short term therapy and when rapid onset of action is required. Above all, the main criteria of these type of antacids is they produce Systemic alkalosis. Example: Sodium bi-carbonate. (NaHCO3)

➤ Non-Systemic Antacids

The term Non-Systemic means affecting a single organ or body part not the entire body.

 They form insoluble compounds. They have poor absorption capacity. They don’t produce any systemic effects. They remain in the gastro-intestinal tract and useful in long term therapy. 

Examples:

1. Magnesium hydroxide [Mg(OH]2
2. Aluminium hydroxide [A1(OH)3
3. Calcium Carbonate [CaCO3]
4. Combined Antacids.

Ingredients used as antacids include:

 Alginates are sometimes combined with antacids for use in gastroesophageal reflux disease. Alginates float on top of the gastric contents and act as a barrier between the acidic contents of the stomach and the lower esophageal sphincter, preventing erosion of the lower esophagus and therefore not creating the pain experienced in gastroesophageal reflux disease. Alginates include sodium alginate and alginic acid. They are present in antacid medications with various brand names.

Some antacids are combined with another medicine called simeticone which helps to reduce wind (flatulence).

➦ How do Antacids work?? 

When the naturally produced mucous barrier that protects the lining of the stomach from being worn away in response to acid is damaged allowing the acid to damage the stomach, causing the ulcer. . In some people, there may be a problem with the muscular band at the top of the stomach (the sphincter) that keeps the stomach tightly closed. This may allow the acid to escape and irritate the gullet (oesophagus). This is called acid reflux, which can cause heartburn and/or inflammation of the gullet (oesophagitis).

Antacids work by neutralizing the acid in your stomach. The ingredients in antacids are basic type which is opposite of acids. A reaction between an acid and base is called neutralization. This neutralization makes the stomach contents less corrosive. This can help to relieve the pain associated with acidity, ulcers and the burning sensation in acid reflux. 

When antacids work on stomach acid, they can produce gas which may cause wind (flatulence). Simeticone helps to stop this foaming effect and may sometimes be included within antacid medications.

Many of the common antacids also include alginates. Most alginates work by forming a gel which floats on top of the stomach contents. The gel acts as a protective barrier, preventing stomach acid from irritating the oesophagus.

➦ When to take Antacids?? 

When antacids are taken on an empty stomach they provide acid reduction for 20 to 40 minutes only because the antacid is rapidly emptied into the duodenum.

 When taken after a meal, (approximately 1 hour afterwards) antacids reduce acid for at least three hours since food from the meal slows emptying of the antacid (and food) from the stomach.  For most people, the best time to take them is with or soon after meals, and just before going to bed. 

It's best to take antacids with food or soon after eating because this is when you're most likely to get indigestion or heartburn.

The effect of the medicine may also last longer if taken with food.

Antacids can affect how well other medicines work, so don't take other medicines within two to four hours of taking an antacid.

It is important to discuss the use of antacids with a physician or pharmacist, especially if used in combination with other prescribed medications so as to avoid drug interactions. 

➦ Dose limit of Antacids? 

1. Antacid ingredients:

• The maximum daily dose of acceptable ingredients should not exceed the following levels:
  • Aluminum hydroxide➠10000 mg
  • Dihydroxyaluminum aminoacetate ➠4000 mg
  • Dihydroxyaluminum sodium carbonate ➠8016 mg
  • Magnesium carbonate ➠3288 mg
  • Magnesium hydroxide ➠7200 mg
  • Magnesium oxide ➠1920 mg
  • Magaldrate ➠10800 mg
  • Calcium carbonate ➠8000 mg
  • Sodium bicarbonate ➠6000 mg
  • Magnesium trisilicate ➠4680 mg
  • Glycine ➠8000 mg

2. Combination non-antacid ingredients:

The maximum daily dose should not provide more than the following levels-

• Alginic acid ➠4000 mg
• Simethicone➠ 640 mg

3. Dosage as an antacid should be specified as being for adults

4. Dosages for mineral supplementation (where applicable) should not exceed those given in the Mineral Supplement Labelling Standard:

• for calcium, up to a maximum of 1500 mg per day
• for magnesium, up to a maximum of 500 mg per day

Warnings: For all ingredients:

1.  Do not take for more than two weeks, or if symptoms recur,       unless directed by a doctor
2. Do not take within two hours of another medicine because the     effectiveness of the other medicine may be altered.
For products containing magnesium or aluminum:

1. Individuals with kidney disease should not take this product except on the advice of a doctor
For products with more than 115 mg sodium in daily dose:

1. Do not use if you are pregnant or on a low salt diet

➦ What are the Side Effects of Antacids?? 

Antacids don't usually have many side effects if they're only taken occasionally and at the recommended dose.

But sometimes they can cause:

• diarrhoea or constipation
• flatulence (wind)
• stomach cramps
• feeling sick or vomiting

 →The carbonate antacids (sodium bicarbonate and calcium carbonate) can cause excessive belching, nausea, abdominal distention, and flatulence. 

These antacids when used in high doses or in patient with kidney failure may result in  metabolic alkalosis.  The possibility of high calcium levels in the blood (hypercalcemia), kidney impairment (renal insufficiency) and metabolic alkalosis increases greatly if high doses of antacids are used with calcium containing milk products. This is know as milk-alkali syndrome.

→Antacids that contain aluminum hydroxide may cause constipation, aluminum-intoxication, osteomalacia (Softening of bones), and hypophosphatemia (Lower than normal level of Phosphate in blood).

→Antacids that contain magnesium have a laxative effect that may cause diarrhea, and in patients with renal failure they may cause increased magnesium levels in the blood, because of the reduced ability of the kidneys to eliminate magnesium from the body in the urine.

→Antacids can cause a rebound effect, which is that it may exacerbate the very condition that it was intended to alleviate. A rebound increase in gastric acid secretion is more likely to occur once chronic use of antacids have been discontinued. 

Antacids should be used cautiously when other drugs are being used simultaneously. It can affect the absorption of certain antibiotics and iron, and can also impair the action of other acid-reducing drugs like sucralfate. This interaction may be minimized by using antacids and other drugs at least 2 hours apart.

➦ How do Antacids interact if taken with other drugs???

All antacids potentially may increase or decrease the rate and/or extent of absorption of concomitantly administered oral drugs by changing GI transit time or by binding or chelating the drug. In vitro studies indicate that magnesium hydroxide or trisilicate has the greatest potential for drug binding and aluminum hydroxide and calcium carbonate are intermediate. 

➧ Antacids have effect on acidic drugs. 

When antacids are taken with acidic drugs (for example, digoxin, phenytoin, chlorpromazine, isoniazid, they cause the absorption of the acidic drugs to be decreased, which causes low blood concentrations of the drugs, which ultimately results in reduced effects of the drugs. 

➧ When Antacids taken with drugs such as pseudoephedrine (Sudafed, Semprex D, Clarinex-D 12hr, Clarinex-D 24hr, , Deconsal, Entex PSE, Claritin D, and more), and levodopa (Dopar), increase absorption of the drugs and can cause toxicity/adverse events due to increased blood levels of the drugs.

➧ Antacids that contain magnesium trisilicate and magnesium hydroxide when taken with some other medications (such as tetracycline) will bind to the drugs, and reduce their absorption and effects.

➧ Antacids containing Sodium bicarbonate has a strong effect on the acidity of the urine, and this can affect the elimination (excretion) of some drugs by the kidney. Thus, sodium bicarbonate inhibits the excretion of basic drugs such as quinidine (Quinidex, Quinidine Gluconate, Quinidine Sulfate, Quinidine Injection) and amphetamines, and increases the excretion of acidic drugs such as aspirin. 

Interaction of Antacids with Specific Drugs and Food

Drug	Interaction	Comments
Aspirin	Pharmacokinetic (increased absorption of buffered or enteric-coated aspirin or decreased blood salicylate concentrations) interactions
Chlordiazepoxide	Possible decreased chlordiazepoxide absorption with aluminum hydroxide and magnesium preparations
Diazepam	Possible increased diazepam absorption with aluminum hydroxide
Digoxin	Possible decreased digoxin absorption	Space doses of the drugs as far apart as possible
Indomethacin	Possible decreased indomethacin absorption	Space doses of the drugs as far apart as possible
Iron salts	Possible decreased absorption of iron salts	Space doses of the drugs as far apart as possible
Isoniazid	Possible decreased isoniazid absorption with aluminum hydroxide	Administer isoniazid at least 1 hour before aluminum-containing antacids
Milk or other calcium-containing foods	Possible milk-alkali syndrome with chronic administration of bicarbonate and milk or calcium
Naproxen	Possible increased naproxen absorption with sodium bicarbonate Possible decreased naproxen absorption with magnesium oxide or aluminum hydroxide
Pseudoephedrine	Possible increased pseudoephedrine absorption with aluminum hydroxide
Tetracyclines	Possible decreased tetracycline absorption	Allow 1–2 hours to elapse between doses of antacids and tetracyclines

➦What are the warnings and precautions before taking antacids?

·   ➧ Antacids (for example, calcium carbonate) when consumed in high doses and for long periods of time may cause acid rebound. Acid rebound is a condition in which the stomach produces even more acid after the consumption of foods and drinks. 

·  ➧  High-dose calcium carbonate and sodium bicarbonate when taken together can cause a condition called milk-alkali syndrome. It’s symptoms include headache, nausea, irritability, and weakness, hypercalcemia (high blood calcium levels), and reduced function of the kidneys.

· ➧ Extensive use of aluminum-containing antacids may cause hypophosphatemia (low phosphate levels in the blood), which in severe cases could lead to muscle weakness, anorexia, and osteomalacia (softening of the bones due to defective bone mineralization).

·  ➧ Antacids containing aluminum hydroxide should be used with caution in patients who have recently suffered massive upper gastrointestinal bleeding.

·   ➧ For patients with conditions such as high blood pressure, chronic heart failure, renal failure and those who have sodium or salt-restricted diets, it is important to pay attention to the sodium level in sodium-based antacid preparations such as sodium bicarbonate

·   ➧ Antacids should not be given to children under six years of age.

Available Worldwide Brands of Antacids?

Alamag, Alamag Plus, Alka-Mints, Alka-Seltzer Gold Effervescent Antacid, Almacone, Almacone II Hi-Potency, ALternaGEL, Alu-Cap, Alu-Tab, Amphojel, Basaljel, Chooz, Citrocarbonate Granules, Di-Gel, Gaviscon, Gaviscon Extra Strength, Genaton, Kudrox, Lowsium, Lowsium Plus, Maalox, Maalox Advanced Regular Strength, Maalox Advanced Maximum Strength, Maalox Antacid/Anti-Gas Maximum Strength, Maalox Max Quick Dissolve Chewables Antacid/Antigas Maximum Strength, Maalox Quick Dissolve Chewables, Maalox Quick Dissolve Chewables Maximum Strength, Maalox TC, Mag-Al, Mag-Al Plus, Mag-Al XS, Mag-Ox, Marblen, Milk of Magnesia, Mygel, Mygel II, Mylanta, Mylanta Children’s Upset Stomach Relief, Mylanta Fast-Acting, Mylanta Fast-Acting Double Strength, Mylanta Fast-Acting Maximum Strength, Mylanta Supreme Fast Acting, Pepcid Complete, Phillips’ Milk of Magnesia, Riopan Plus, Riopan Plus Double Strength, Rolaids Antacid, Rulox, Tempo, Titralac Extra Strength, Titralac Plus, Titralac Regular, Tums Antacid/Calcium Supplement, Tums E-X Antacid/Calcium Supplement, Tums Ultra Antacid/Calcium Supplement, Uro-Mag. 

What antacids are available in Bangladesh ? 

Brand Name	Contains	Dosage Form	Manufacturer	Price(Tk.)
ACME S MILK OF MAGNESIA	Magnesium hydroxide BP 400mg/5ml	Suspension	Acme Laboratories Ltd.	114ml bot: 13.14 MRP
MAGMIL	Magnesium hydroxide BP 400mg/5ml	Suspension	Pacific Pharmaceuticals Ltd.	100ml bot: 28.00 MRP 200ml bot: 50.00 MRP
MAGNASON	Magnesium hydroxide BP 400mg/5ml	Suspension	Jayson Pharmaceuticals Ltd.	100ml bot: 12.50 MRP
MILK OF MAGNESIA	Magnesium hydroxide BP 412mg/5ml	Suspension	Doctor's Chemical Works Ltd.	114ml bot: 13.00 MRP
MILK OF MAGNESIA	Magnesium hydroxide BP	Suspension	Gaco Pharmaceutical Ltd.	100ml bot: 12.61 MRP
MILK OF MAGNESIA	Magnesium hydroxide BP	Suspension	Millat Pharmaceuticals Limited	100ml bot: 19.50 MRP
MILK OF MAGNESIA	Magnesium hydroxide BP 8% w/w	Suspension	Modern Pharmaceuticals Ltd.	100ml bot: 15.00 MRP
MILK OF MAGNESIA	Magnesium hydroxide BP	Suspension	Orion Laboratories Ltd.	100ml bot: 11.55 MRP
MILK OF MAGNESIA	Magnesium hydroxide	Suspension	Pharmadesh Laboratories Ltd.	100ml bot: 14.00 MRP
MILK OF MAGNESIA	Magnesium hydroxide	Suspension	Seema Pharmaceuticals Limited	114ml bot: 15.00 MRP
MILK OF MAGNESIA-AL	Magnesium hydroxide BP 400mg/5ml	Suspension	Aexim Pharmaceuticals Ltd.	114ml bot: 13.00 MRP
Brand Name	Contains	Dosage Form	Manufacturer	Price(Tk.)
XCID	Calcium carbonate BP 1000mg/tablet	Tablet (chewable)	Square Pharmaceuticals Ltd.	30s pack: 60.00 MRP
Brand Name	Contains	Dosage Form	Manufacturer	Price(Tk.)
ACEDONE-Z	Dried aluminium hydroxide gel & magnesium hydroxide BP	Tablet	Zenith pharmaceuticals ltd.	250s pack: 132.50 MRP
ACEDONE-Z	Aluminium hydroxide gel BP & magnesium hydroxide BP	Suspension	Zenith pharmaceuticals ltd.	200ml bot: 32.50 MRP
ACIDAX	Aluminium hydroxide gel 180mg & magnesium hydroxide 200mg/5ml	Suspension	Apollo pharmaceutical laboratories ltd.	200ml bot: 31.40 MRP
ACIDROX	Aluminium hydroxide gel BP & magnesium hydroxide BP	Suspension	Syntho laboratories ltd.	200ml bot: 32.00 MRP
ACIDROX-M	Dried aluminium magnesium polyhydroxy complex USP	Magaldrate tablet	Syntho laboratories Ltd.	150s pack: 150.00 MRP
ACIDROX-M	Hydroxy magnesium aluminate or magaldrate USP	Magaldrate suspension	Syntho laboratories Ltd.	200ml bot: 50.00 MRP
ALGEX	Dried aluminium hydroxide gel & magnesium hydroxide	Tablet	Doctor's Chemicals Works Ltd.	200s pack: 100.00 MRP
ALGEX	Aluminium hydroxide gel 380mg & magnesium hydroxide 125mg/5ml	Suspension	Doctor's Chemicals Works Ltd.	200ml bot: 32.30 MRP
ALIDEX	Dried aluminium hydroxide gel & magnesium hydroxide	Tablet	Rasa Pharmaceuticals Ltd.	200s pack: 105.00 MRP
ALIDEX	Aluminium hydroxide compressed gel BP & magnesium hydroxide BP	Suspension	Rasa Pharmaceuticals Ltd.	200ml bot: 29.00 MRP
ALIMAG	Dried aluminium hydroxide gel & magnesium hydroxide BP	Tablet	Asiatic Laboratories Ltd.	200s pack: 100.00 MRP
ALUCIL-S	Dried aluminium hydroxide gel BP & magnesium hydroxide BP & simethicone (activated dimethicone) 30mg/tablet	Tablet	Opsonin pharma Ltd.	100s pack: 90.00 MRP
ALUGEL	Dried aluminium hydroxide gel BP 250mg & magnesium hydroxide BP 400mg /tablet	Tablet	Cosmic Chemical Industries Ltd.	200s pack: 100.00 MRP
ANCIDPLUS (DS)	Aluminium hydroxide gel BP & magnesium hydroxide BP	Suspension	Renata Limited	200ml bot: 46.00 MRP
ANTAMEAL	Dried aluminium hydroxide gel & magnesium hydroxide BP	Tablet	Alco Pharma Ltd.	200s pack: 100.00 MRP
ANTANIL Plus	Aluminium hydroxide gel 400mg, magnesium hydroxide 400mg & simethicone 30mg/5ml	Suspension	IBN SINA Pharmaceutical Industry Ltd.	200ml bot: 55.00 MRP
APCOCID	Dried aluminium hydroxide gel BP 250mg & magnesium hydroxide BP400mg/tablet	Tablet	Supreme Pharmaceuticals Limited	100s pack: 50.00 MRP
APEDROX	Aluminium hydroxide gel BP & magnesium hydroxide BP	Suspension	APC Pharmaceuticals Ltd.	200ml bot: 30.00 MRP
AVLOCID	Dried aluminium hydroxide 400mg, magnesium hydroxide 400mg & simethicone (activated dimethicone) 30mg/tablet	Tablet	ACI Ltd.	250s pack: 300.00 IP
AVLOCID	Aluminium hydroxide gel 400mg, magnesium hydroxide 400mg & simethicone 30mg/5ml	Suspension	ACI Ltd.	200ml bot: 55.00 IP
Brand Name	Contains	Dosage Form	Manufacturer	Price(Tk.)
AEROPAC	Simethicone USP 67mg/ml	Drop	Amico Laboratories Ltd.	15ml drop: 25.00 MRP
FLACOL	Simethicone USP 67mg/ml	Drop	Square Pharmaceuticals Ltd.	15ml drop: 30.00 MRP
LEFOAM	Simethicone USP 67mg/ml	Drop	Incepta Pharmaceuticals Ltd.	15ml drop: 30.00 MRP
NEODROP	Simethicone USP 67mg/ml	Drop	Beximco Pharmaceuticals Ltd.	15ml drop:30.00
PEDICON	Simethicone USP 67mg/ml	Drop	Orion Laboratories Ltd.	10ml drop: 25.00 MRP; 20ml drop: 30.00 MRP
SEMECON	Simethicone USP 67mg/ml	Drop	Drug International Ltd.	15ml drop: 30.00 MRP
SIMECOL	Simethicone USP 67mg/ml	Drop	Alco Pharma Ltd.	15ml drop: 28.00 MRP
SIMICON	Simethicone USP 67mg/ml	Drop	Navana Pharmaceuticals Ltd.	15ml drop: 30.00 MRP

This is all for today. In my next post, I'll be discussing about other category of medicines that can used in treating acidity and other problems caused due to excessive stomach acid. Till then, happy reading!!