Gaviscon Extra Relief Formula Side Effects
Generic Name: alginic acid / aluminum hydroxide / magnesium carbonate
Note: This page contains information about the side effects of alginic acid / aluminum hydroxide / magnesium carbonate. Some of the dosage forms included on this document may not apply to the brand name Gaviscon Extra Relief Formula.
Applies to alginic acid / aluminum hydroxide / magnesium carbonate: oral suspension, oral tablet chewable
Gastrointestinal side effects have been reported the most frequently. These have included constipation (secondary to aluminum hydroxide therapy) and diarrhea (secondary to magnesium carbonate therapy). These agents are combined so lower doses may be used and the constipating and diarrheal effects may be balanced out. However, diarrhea tends to be the dominating effect, regardless of the ratio. Rarely, gastrointestinal obstruction has occurred with the use of aluminum hydroxide.[Ref]
Patients with renal failure may be at risk of aluminum toxicity because of ingestion of aluminum hydroxide and because of exposure to aluminum-containing water used for dialysate solutions. Adverse effects of aluminum accumulation in these patients has led to monitoring of water source aluminum content by dialysis units and periodic measurements of serum aluminum in patients undergoing chronic dialysis.
High aluminum concentrations in patients are generally also associated with high daily ingestion. One study suggested that increased aluminum concentrations in uremic patients was most significant with daily doses greater than 3 grams of aluminum hydroxide. Patient age is also associated with aluminum concentrations. Younger patients typically demonstrate higher concentrations.
Concurrent administration of aluminum hydroxide with citrate containing products has been associated with unusually high serum concentrations of aluminum and, especially in cases of renal failure, severe toxicity. Citrate may increase aluminum solubility and absorption.
Aluminum concentrations during aluminum hydroxide therapy have also been correlated with body iron stores. One study demonstrated a negative correlation between serum aluminum concentrations and serum ferritin levels. It was postulated that high serum ferritin and high transferritin saturation might hamper gut absorption of aluminum.
During long-term use, aluminum has been shown to deposit in bone, joint, and brain.
Signs and symptoms of hypermagnesemia may include hypotension, nausea, vomiting, EKG changes, respiratory depression, loss of deep tendon reflex, dilated pupils, altered mental status, and coma.[Ref]
Although the majority of aluminum ingested is eliminated by the gastrointestinal tract, absorption of aluminum and increases in serum concentrations have been demonstrated. Accumulation of aluminum and resulting toxicity is generally confined to patients with renal dysfunction and impaired elimination of aluminum.
Magnesium may be systemically absorbed following administration of magnesium salts. In patients with normal renal function, increased magnesium elimination in the urine occurs and no significant changes in serum magnesium levels would be expected. However, magnesium may accumulate in patients with renal insufficiency.[Ref]
Metabolic side effects have included hypophosphatemia with the use of aluminum hydroxide. In patients on long-term aluminum hydroxide therapy, especially in association with poor diets, hypophosphatemia may result in muscle weakness, rhabdomyolysis, hemolysis, and encephalopathy.[Ref]
Aluminum hydroxide complexes with phosphate in the gut to form insoluble aluminum phosphate, thus inhibiting the absorption of dietary phosphate. Aluminum hydroxide is commonly used in patients with renal dysfunction to regulate the accumulation of phosphate.
Hypophosphatemia is thought to stimulate the conversion of calcifediol (25-hydroxy vitamin D3) to calcitriol (1,25-dihydroxy vitamin D3), a potent stimulator of calcium and phosphorus intestinal absorption and osteoclastic resorption. Hypercalciuria is generally associated with hypophosphatemia.[Ref]
Aluminum hydroxide associated hypophosphatemia, if severe and chronic, can result in decreased bone mineralization and potentially osteomalacia. Hypophosphatemia is also thought to stimulate the conversion of calcifediol (25-hydroxy vitamin D3) to calcitriol (1,25-dihydroxy vitamin D3), a potent stimulator of osteoclastic resorption, and thereby contribute to osteomalacia. Patients generally require phosphorus replacement therapy. Symptoms of osteomalacia may take several weeks to resolve.
Osteomalacia due to aluminum deposition in bone is generally only seen in patients with chronic renal failure. Bone formation slows in response to aluminum bone deposits. Aluminum may also deposit in joint tissue, resulting in arthropathy and hydrarthrosis.[Ref]
Musculoskeletal side effects have included osteomalacia, due to aluminum hydroxide, which may occur by two different mechanisms. Osteomalacia may occur due to hypophosphatemia or due to aluminum accumulation in bone. Osteomalacia due to hypophosphatemia is often accompanied by malaise, bone pain, muscular weakness, and bone fractures. Osteomalacia due to aluminum deposition may present in a similar fashion and occurs predominately in patients with chronic renal failure. Aluminum deposits typically can be observed on bone biopsy.[Ref]
Encephalopathy associated with aluminum accumulation is characterized by speech disorders, dysarthria, dyspraxia, dysphasia, tremor, myoclonus, seizures, coma, and ultimately death. EEG of patients with aluminum encephalopathy may show paroxysmal slowing and diffuse rhythmical bursts of delta activity.
The interval between commencement of aluminum hydroxide therapy and development of encephalopathy in eight reported cases ranged from three weeks to three months. In two of these patients, aluminum serum concentrations ranged from 871 to 2267 mcg/L. These patients were also on sodium citrate therapy which enhances GI aluminum absorption. Most chronic dialysis patients develop aluminum encephalopathy slowly over many years.[Ref]
Nervous system side effects have included encephalopathy which has occasionally been reported in patients with renal failure on long-term therapy with aluminum hydroxide. When available, basal and/or deferoxamine stimulated aluminum serum levels reveal high concentrations.[Ref]
Renal side effects have rarely included formation of renal calculi, most probably due to hypercalciuria, with the use of aluminum hydroxide.[Ref]
Antacids may interfere with drug therapies because of their effect on gastric pH, adsorption or binding to drugs, and changes in urinary pH.[Ref]
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2. Johansson G, Backman U, Danielson BG, Fellstrom B, Ljunghall S, Wikstrom B "Effects of magnesium hydroxide in renal stone disease." J Am Coll Nutr 1 (1982): 179-85
3. Girotti MJ, Ruddan J, Cohanim M "Amphojeloma: antacid impaction in a critically ill patient." Can J Surg 27 (1984): 379-80
4. Johansson G, Backman U, Danielson BG, Fellstrom B, Ljunghall S, Wikstrom B "Magnesium metabolism in renal stone formers. Effects of therapy with magnesium hydroxide." Scand J Urol Nephrol Suppl 53 (1980): 125-34
5. Bakir AA, Hryhorczuk DO, Ahmed S, Hessl SM, Levy PS, Spengler R, Dunea G "Hyperaluminemia in renal failure: the influence of age and citrate intake." Clin Nephrol 31 (1989): 40-4
6. Kirschbaum BB, Schoolwerth AC "Acute aluminum toxicity associated with oral citrate and aluminum- containing antacids." Am J Med Sci 297 (1989): 9-11
7. Huang JY, Huang CC, Lim PS, Wu MS, Leu ML "Effect of body iron stores on serum aluminum level in hemodialysis patients." Nephron 61 (1992): 158-62
8. Main J, Ward MK "Potentiation of aluminium absorption by effervescent analgesic tablets in a haemodialysis patient." BMJ 304 (1992): 1686
9. Weberg R, Berstad A, Aaseth J, Falch JA "Mineral-metabolic side effects of low-dose antacids." Scand J Gastroenterol 20 (1985): 741-6
10. Covington TR, Lawson LC, Young LL, eds. "Handbook of Nonprescription Drugs. 10th ed." Washington, DC: American Pharmaceutical Association (1993):
11. Poisson M, Mashaly R, Lebkiri B "Dialysis encephalopathy: recovery after interruption of aluminium intake." Br Med J 2 (1978): 1610-1
12. Johansson G, Backman U, Danielson BG, Fellstrom B, Ljunghall S, Wikstrom B "Biochemical and clinical effects of the prophylactic treatment of renal calcium stones with magnesium hydroxide." J Urol 124 (1980): 770-4
13. Ittel TH, Gladziwa U, Muck W, Sieberth HG "Hyperaluminaemia in critically ill patients: role of antacid therapy and impaired renal function." Eur J Clin Invest 21 (1991): 96-102
14. Brahm M "Serum-aluminum in nondialyzed chronic uremic patients before and during treatment with aluminum-containing phosphate-binding gels." Clin Nephrol 25 (1986): 231-5
15. Ludwig GD, Kyle CG, de Blanco M ""Tertiary" hyperparathyroidism induced by osteomalacia resulting from phosphorus depletion." Am J Med 43 (1967): 136-40
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17. Insogna KL, Bordley DR, Caro JF, Lockwood DH "Osteomalacia and weakness from excessive antacid ingestion." JAMA 244 (1980): 2544-6
18. Carmichael KA, Fallon MD, Dalinka M, Kaplan FS, Axel L, Haddad JG "Osteomalacia and osteitis fibrosa in a man ingesting aluminum hydroxide antacid." Am J Med 76 (1984): 1137-43
19. Cooke N, Teitelbaum S, Avioli LV "Antacid-induced osteomalacia and nephrolithiasis." Arch Intern Med 138 (1978): 1007-9
20. Baker LR, Ackrill P, Cattell WR, Stamp TC, Watson L "Iatrogenic osteomalacia and myopathy due to phosphate depletion." Br Med J 3 (1974): 150-2
21. Sherrard DJ, Ott SM, Andress DL "Pseudohyperparathyroidism. Syndrome associated with aluminum intoxication in patients with renal failure." Am J Med 79 (1985): 127-30
22. Kingswood C, Banks RA, Bunker T, Harrison P, Mackenzie C "Fracture osteomalacia." Lancet 1 (1983): 70-1
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24. Heaf JG, Podenphant J, Joffe P, Andersen JR, Fugleberg S, Braendstrup O "The effect of oral aluminium salts on the bone of non-dialysed uremic patients." Scand J Urol Nephrol 21 (1987): 229-33
25. Alfrey AC, LeGendre GR, Kaehny WD "The dialysis encephalopathy syndrome. Possible aluminum intoxication." N Engl J Med 294 (1976): 184-8
26. Pillion G, Loirat C, Blum C, Poisson M, Bacri JL, Broyer M, Mathieu H "Aluminium encephalopathy: a potential risk of aluminium gels in children with chronic renal failure." Int J Pediatr Nephrol 2 (1981): 29-32
27. Sideman S, Manor D "The dialysis dementia syndrome and aluminum intoxication." Nephron 31 (1982): 1-10
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