Not all Maalox are Equal

Not all Maalox products are interchangeable. Most parents think of antacids (for heartburn) when they hear the name Maalox, but Maalox Total Relief contains an anti-diarrheal agent. Recently, the FDA warned consumers to avoid Maalox mix-ups because the active ingredient in Maalox Total Relief, bismuth subsalicylate (related to aspirin), can cause serious side effects if it is taken by children and adults who are at risk for bleeding excessively. One such risk factor is having a history of gastrointestinal ulcers or bleeds. Another risk is taking anti-diabetic medicines, blood-thinning medicines (warfarin, aspirin), and nonsteroidal anti-inflammatory agents (ibuprofen, naproxen). Children and teenagers who are recovering from viral illnesses (chicken pox or flu-like illnesses) should also steer clear of aspirin-containing products to avoid Reye's Syndrome. Finally, patients allergic to aspirin should not take anything containing bismuth subsalicylate.

Novartis, the manufacturer, has agreed to rename Maalox Total Relief to remove the name Maalox and change the graphics to make it clearer that these are different products. You won't see these new packages until later in September. Until then, ask your pharmacist to make sure you're buying the right product for your child or yourself. Ask yourself: what is it that's bothering your child?

• Is it just gas? You can just get plain simethicone (Gas X, Mylicon, or generic equivalents) for gas relief.
• If your child has heartburn, acid indigestion, sour stomach, or upset stomach from these symptoms, but no gas, then Maalox Children's Relief will be appropriate.
  
• If your child is 6 and older and also needs gas relief, then choose Maalox Junior Plus.
  
• For children 12 and older with diarrhea and upset stomach and not recovering from a viral illness, try Maalox Total Relief. For heartburn, sour stomach, and acid indigestion relief without gas, try Maalox Regular Strength Chewable.
  
• Gas is also the problem? Then try either Maalox Advanced Maximum Strength Chewable Tablets or Maalox Advanced Regular Strength Liquid. Note that the Advanced Maximum Strength (as compared to Regular Strength) chewable tablets and the Advanced Regular Strength liquid both have simethicone, but they have different antacids. Here it becomes a preference of dosage form, as both will be effective against heartburn, acid indigestion, sour stomach, and upset stomach from these symptoms.
  

To identify which active ingredients each product contains, read the label under "Drug Facts." Below is a table that lists the active ingredients and the products that contain them. Please visit the manufacturer's web site for more detailed information. Report and side effects to the Medwatch program (that's how the FDA picked up that there is a potential danger when these products are confused).

	Active Ingredients	Indications
Maalox Children’s Junior Relief Chewable	Calcium carbonate	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms
Maalox Junior Plus	Calcium carbonate, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, bloating and pressure (gas)
Maalox Regular Strength Chewable Tablets	Calcium carbonate	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms
Maalox Advanced Maximum Strength Chewable Tablets	Calcium carbonate, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, bloating and pressure (gas)
Maalox Advanced Regular Strength Liquid	Aluminum hydroxide, magnesium hydroxide, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, pressure and bloating (gas)
Maalox Total Relief	Bismuth subsalicylate	Diarrhea, upset stomach associated with nausea, heartburn, and gas from overeating

Is it really candy or is it medicine?

As I'm sitting and eating my daughter's trick-or-treat candy, I can remember how upset I was when I heard someone tell my daughter that the chewable acetaminophen tablets were candy so that she would take it.  Many candies look like the medicine that you may have in your home. For example, green m&m's look like green iron pills that many adults take every day. When left unattended, children may sneak the colorful pills into their mouths, mistaking them for candy. Here are some helpful hints on how to get your kids to take their medicine. Some safety tips for poison prevention can be found in an article in Parents magazine. Other tips can be found on the web site for the American Association of Poison Prevention. Also, keep the phone number for the Poison Control Center near your phone, and call if you think there might have been an exposure. Teach the number to your children: 1-800-222-1222 and that medicine is not candy.

Does your child usually suffer from asthma in the fall?

If  your child was off, or on lower dosages, of asthma controller medicines over the summer, have they been resumed, yet? A review of kids' health insurance data presented earlier this week at an American College of Chest Physicians meeting (Chest 2008) found that the peak months for emergency room visits and hospitalizations are October and November, while medication use peaked in December.  Summer is the low season for seeking health care for asthma and use of asthma meds.  I agree with the strategy to restart controller medicines before predicted attacks occur, instead of waiting until one hits.

When I was working as a pediatric clinical pharmacist, September marked the beginning of my busy season for asthma education, and it would continue into the winter months. So, this trend is in line with what was reported in the study. Many of my patients' asthma attacks were triggered by weather changes, seasonal allergies, or a cold. Not taking medicine properly was another reason.  Here are some of my favorite teaching points: 

• Be consistent about the timing of the doses and don't stop medicines without consulting your child's doctor; 
• If the doctor says it's ok to stop or give lower doses during the summer, don't forget to ask when to restart them. Some children have attacks triggered by high humidity in the summertime, so it is possible that your child may need it all year round, especially if there are chronic exposures to other common triggers;
• Don't forget to refill prescriptions.  Many kids end up in the hospital because they run out of their inhalers;
• Make sure the correct technique is being used to give the medicines, especially inhalers. Ask your pharmacist, nurse, or doctor to show you;
  
• Understand how and why the medicines work and teach your child. For example, using the controller medicines during an acute asthma attack does not help; 
• Ask questions about your child's asthma, even if you, or someone you know, has asthma; and
• Oh, don't forget that flu annual flu shot!