NEXIUM (esomeprazole magnesium trihydrate) is indicated for treatment of conditions where a reduction in gastric acid secretion is required such as:

• reflux esophagitis

  
  

• maintenance treatment of patients with reflux esophagitis

  
  

• nonerosive reflux disease (NERD) (i.e. heartburn and regurgitation)

  
  

• healing of NSAID{*Note: Superiority of NEXIUM over ranitidine150 mg BID with the use of non-selective NSAIDs was demonstrated. Superiority was not established with the use of COX-2 selective NSAIDs alone due to the small number of patients analysed in this subgroup.}-associated gastric ulcers

  
  

• reduction of risk of NSAID-associated gastric ulcers

  
  

• treatment of pathological hypersecretory conditions, including Zollinger-Ellison syndrome

  
  

• H. pylori eradication

  
  

 

NEXIUM, in combination with clarithromycin and amoxicillin, is indicated for the treatment of patients with duodenal ulcer disease associated with H. pylori infection to eradicate the H. pylori and heal ulcers. Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

• Hypersensitivity to esomeprazole, substituted benzimidazoles or any of the components of this medication (see Dosage Forms, Composition and Packaging).

  
  

• When used for eradication of H. pylori, the contraindications for amoxicillin and clarithromycin as found in the corresponding Product Monographs should be taken into consideration.

  
  

In the presence of any alarm symptom (e.g., significant unintentional weight loss, recurrent vomiting, dysphagia, hematemesis or melena), and/or when gastric ulcer is suspected or present, malignancy should be excluded, as treatment may alleviate symptoms and delay diagnosis.

Long-term toxicity studies of omeprazole, revealed the gastric mucosa as the target organ. The carcinogenic potential of esomeprazole was assessed using omeprazole studies. In the rat carcinogenicity study (24 months), ECL-cell carcinoids were found in some animals treated with 14-140 mg/kg/day for their normal life span. ECL-cell carcinoids were seen in a background of ECL-cell hyperplasia. No ECL-cell carcinoids were identified in the carcinogenicity study in mice or in long-term (up to 7 years) general toxicity studies in dogs.

A vast number of studies have revealed that pronounced and sustained hypergastrinemia is the mechanism behind the development of the gastric ECL-cell carcinoids in the rat. Such ECL carcinoids have been seen in rats after life-long treatment with other inhibitors of acid secretion such as H2-receptor blockers and other proton pump inhibitors. Partial fundectomy in rats results in hypergastrinemia and gastric ECL-cell carcinoids in the remaining part of the fundic mucosa, towards the end of the rats' life span.

Treatment with NEXIUM for up to 1 year in more than 800 patients has not resulted in any significant pathological changes in the gastric oxyntic endocrine cells. Short-term treatment and long-term treatment with the racemate, omeprazole, capsules in a limited number of patients for up to 11 years have not resulted in any significant pathological changes in gastric oxyntic endocrine cells.

During treatment with all antisecretory drugs serum gastrin increases in response to the decreased acid secretion. The effect of NEXIUM on serum gastrin concentrations was evaluated in approximately 2700 patients in clinical trials up to 8 weeks and in over 1300 patients for up to 6-12 months (daily doses of either 20 or 40 mg). The mean fasting gastrin level increased in a dose-related manner. This increase reached a plateau (approximately 100 pg/mL) within two to three months of therapy and returned to baseline levels (approximately 30-40 pg/mL) within four weeks after discontinuation of therapy.

The safety of NEXIUM (esomeprazole magnesium trihydrate) in pregnancy has not been established. NEXIUM tablets should not be administered to pregnant women unless the expected benefits outweigh the potential risks.

It has not been investigated whether or not esomeprazole is excreted in human breast milk. No studies in lactating women have been performed. Therefore, NEXIUM tablets should not be given to nursing mothers unless its use is considered essential.

The safety and effectiveness of NEXIUM tablets in children have not yet been established.

The metabolism of NEXIUM (esomeprazole magnesium trihydrate) is not significantly changed in elderly subjects. Following repeated oral dosing with 40 mg NEXIUM in healthy elderly subjects (6 males, 8 females; 71 to 80 years of age), AUC and C_max values measured were similar to those previously measured in young GERD patients (ratio of AUC values in elderly vs. GERD subjects: 1.25; ratio of C_max values: 1.18). Therefore, dose adjustment is not required in the elderly.

The AUC and C_max values were slightly higher (13%) in females than in males at steady state. Dosage adjustment based on gender is not necessary.

The metabolism of esomeprazole magnesium in patients with mild to moderate liver dysfunction (Child Pugh Class A or B), is similar to that in patients with symptoms of GERD with normal liver function. Metabolism of esomeprazole is decreased in patients with severe liver dysfunction (Child Pugh Class C) resulting in a doubling of the area under the plasma concentration-time curve of esomeprazole. The plasma elimination half-life in patients with severe liver dysfunction is still very short (3 hours) relative to the dosing interval (24 hours). Esomeprazole and its major metabolites do not show any tendency to accumulate with once-daily dosing. Dose adjustment is not required in patients with mild to moderate liver impairment. A daily dose of 20 mg in patients with severe liver disease should not, as a rule, be exceeded (see Dosage and Administration).

Since the kidney is responsible for the excretion of metabolites of esomeprazole but not for the elimination of the parent compound, the metabolism of esomeprazole is not expected to be changed in patients with impaired renal function. Esomeprazole is extensively protein-bound and is, therefore, not expected to be readily dialyzable. Dose adjustment is not required in patients with impaired renal function (see Dosage and Administration).

The CYP 2C19 and CYP 3A4 isozymes are responsible for metabolism of esomeprazole. CYP 2C19, which is involved in the metabolism of all available proton pump inhibitors, exhibits polymorphism. Approximately 3% of Caucasians and 15-20% of Asians lack CYP 2C19 and are termed "poor metabolizers". At steady state, the ratio of AUC in poor metabolizers to AUC in the rest of the population is approximately 2. Dosage adjustment of NEXIUM based on CYP 2C19 status is not necessary.

The clinical documentation for NEXIUM does not support the need for routine laboratory monitoring of response to therapy. (See Warnings and Precautions, Carcinogenesis and Mutagenesis for effects of NEXIUM on serum gastrin levels and Adverse Reactions, Post-market Adverse Drug Reactions for effects on liver functioning.)

NEXIUM (esomeprazole magnesium trihydrate) is well-tolerated. Most adverse reactions have been mild and transient, showing no consistent relationship with treatment. Adverse reactions have been recorded during controlled clinical investigations in >8500 patients exposed to NEXIUM. Additionally >1200 subjects/patients were exposed to NEXIUM in Phase I studies. Among reactions which occurred with a frequency of >1% in clinical studies, only headache, diarrhea, flatulence, abdominal pain, nausea, vomiting, dizziness and dry mouth are thought to be associated with the use of NEXIUM.

Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.

The following adverse reactions, irrespective of causal relationship, were reported (at a rate of more than 1%) in controlled short-term (up to 8 weeks) clinical trials involving 5668 patients (see Table 1).

Table 1: NEXIUM

Percentage of Patients Reporting Adverse Reactions, Irrespective of Causal Relationship, (at a Rate of More than 1%) in Short Term Clinical Trials (Up to 8 weeks) Treated With NEXIUM

Adverse Reaction	All studies	Placebo controlled studies
	NEXIUM (20 & 40 mg) n=5668 (%)	NEXIUM (20 & 40 mg) n=470 (%)	Placebo n=240 (%)
Body as a Whole
Headache	8.4	6.6	7.5
Gastrointestinal
Diarrhea	5.7	5.7	4.2
Abdominal Pain	3.6	5.7	2.5
Nausea	3.5	5.1	5.4
Flatulence	3.3	3.2	—
Gastritis	2.1	—	—
Constipation	1.6	1.7	1.3
Vomiting	1.4	1.1	1.7
Mouth Dry	1.3	1.3	—
Respiratory
Respiratory Infection	3.8	1.9	3.8
Sinusitis	1.7	2.8	2.5
Pharyngitis	1.3	0.4	1.3
Nervous System
Dizziness	1.2	0.9	1.7
Resistance Mechanism
Viral infection	1.1	—	0.4

In clinical trials up to 6 months' duration, the following adverse events were reported (see Table 2).

Table 2: NEXIUM

Percentage of Patients Reporting Adverse Reactions, Irrespective of Causal Relationship, (at a Rate of More than 3%) in Clinical Trials Up to 6 Months' Duration Treated With NEXIUM

Adverse Reaction	NEXIUM (10, 20 and 40 mg) n=519 (%)	Placebo n=169 (%)
Body as a Whole
Headache	6.6	4.1
Gastrointestinal
Gastritis/Gastritis Aggravateda	6.2	5.3
Flatulence	5.0	1.8
Diarrhea	6.7	3.0
Abdominal Pain	3.7	2.4
Nausea/Nausea Aggravated	4.8	2.4
Vomiting/Vomiting Aggravated	3.3	1.2
Respiratory
Respiratory Infection	8.5	3.0
Sinusitis	4.2	1.8
Resistance Mechanism
Viral Infection	3.7	1.8
Miscellaneous
Accident and/or Injury	3.7	1.8

^a. Endoscopic assessment.

Additionally, the following adverse reactions (irrespective of causality) were each reported at a rate of >1% with NEXIUM in these same long-term studies (n=519): rash, fracture, hernia, dizziness, duodenitis, dyspepsia, epigastric pain, serum gastrin increased, gastroenteritis, GI mucosal discoloration, esophageal disorder, tooth disorder, ALT (alanine transferase) increased, hypertension, coughing, rhinitis, anemia, benign GI neoplasm, back pain, chest pain, and fatigue.

Clinical experience for up to one year in over 800 patients with doses of NEXIUM of 40 mg have shown a similar adverse reaction pattern to that seen in short-term trials. In addition to the adverse reactions listed above, the following adverse reactions were reported (at a rate of more than 1%), irrespective of causal relationship (mean duration of treatment=294 days): accident/injury (7.6%), pain (4.3%), urinary tract infection (3.7%), bronchitis (3.6%), arthralgia (2.9%), hypertension (2.6%), allergy (2.1%), insomnia (2.1%), hypercholesterolemia (2.0%), anxiety (1.7%), gastroesophageal reflux (1.6%), fever (1.5%), ear infection (1.5%), flu-like disorder (1.4%), myalgia (1.2%), arthropathy (1.1%), dyspnea (1.1%), overdose (1.1%).

In clinical studies, a total of 446 patients received NEXIUM in combination with amoxicillin and clarithromycin for 7 days. The following adverse reactions were reported (at a rate of more than 1%), irrespective of causal relationship: diarrhea (21.5%), taste perversion (12.6%), headache (3.6%), dry mouth (3.4%), ALT increased (1.8%), flatulence (1.6%), nausea (1.3%), stomatitis (1.3%), vomiting (1.1%) and pharyngitis (1.1%). However, it should be noted that taste perversion is commonly associated with clarithromycin treatment and diarrhea is commonly associated with antibiotic treatment.

When NEXIUM is used in combination with amoxicillin and clarithromycin, the Product Monographs for those agents must be consulted and followed.

The data presented in this section is derived from two short-term gastric ulcer healing studies comprising 836 patients.

Table 3: NEXIUM

Percentage of Patients Reporting Adverse Reactions that were Assessed by the Investigator to Have a Reasonable Causal Relationship with Treatment (at a Rate of >1%) in Short Term Clinical Trials (up to 8 Weeks), for the Healing of Gastric Ulcers Associated with NSAID Therapy

Adverse Reactions	NEXIUM (20 & 40 mg qd) n=556 (%)	Ranitidine (150 mg bid) n=280 (%)
Gastrointestinal
Flatulence	2.5	3.6
Gastritis	1.8	0.7
Diarrhea	1.6	0.7
Dyspepsia/Dyspepsia aggravated	1.6	2.5

The following adverse reactions occurred (<1% for NEXIUM) in clinical trials for the healing of gastric ulcers associated with NSAID therapy, and were considered causally related by the investigator:

abdominal pain, epigastric pain, gastric retention, gastric ulcer, gastroesophageal reflux, nausea, peptic ulcer aggravated.

abnormal hepatic function, increased AST, increased ALT.

increased phosphatase alkaline.

headache.

insomnia.

taste perversion.

The following adverse events (considered unrelated to esomeprazole by the investigator) were each reported at a frequency of >1% in clinical trials for the healing of gastric ulcers; gastric ulcer aggravated, mucosal discoloration GI, gastrointestinal symptoms NOS, esophageal stricture, esophagitis, vomiting, constipation, duodenitis, rash, anxiety, pharyngitis, respiratory infection, sinusitis, urinary tract infection, accident and/or injury, and back pain.

In addition, the following adverse events of a potentially severe nature (considered unrelated to esomeprazole by the investigator) were reported in these same studies; cardiac failure aggravated, hypertension/hypertension aggravated, syncope, arrhythmia, bradycardia, atrial fibrillation, palpitation/palpitation aggravated.

The data presented in this section is derived from two long-term ulcer risk-reduction studies comprising 1390 patients.

Table 4: NEXIUM

Percentage of Patients Reporting Adverse Reactions that were Assessed by the Investigator to have a Reasonable Causal Relationship with Treatment (at a Rate of >1%) in Long Term Clinical Trials (up to 6 Months), for the Risk-reduction of Gastric Ulcers Associated with NSAID Therapy

Adverse Reaction	NEXIUM (20 & 40 mg qd) n=936 (%)	Placebo n=454 (%)
Gastrointestinal
Flatulence	4.0	3.7
Gastritis/Gastritis aggravated	2.2	2.9
Gastrointestinal symptoms	2.0	2.6
Gastroesophageal reflux	1.9	3.5
Dyspepsia/Dyspepsia aggravated	1.9	3.7
Nausea/Nausea aggravated	1.7	2.0
Abdominal Pain	1.4	0.9
Diarrhea	1.1	0.9

The following adverse reactions occurred (<1% for NEXIUM) in clinical trials for the risk-reduction of gastric ulcers associated with NSAID therapy, and were considered causally related by the investigator:

asthenia, back pain.

anemia, leukopenia, thrombocytopenia.

constipation, defecation urge, duodenitis, epigastric pain, eructation, gastric retention, gastric ulcer, dry mouth, mucosal discolouration GI, frequent stools, vomiting.

hepatic enzymes increased NOS, increased AST, increased ALT.

dehydration, weight decrease, weight increase.

GI neoplasm.

dizziness, headache, hyperesthesia, vertigo.

anorexia, increased appetite, insomnia, sleep disorder.

herpes simplex.

rash.

taste perversion.

The following adverse events (considered unrelated to esomeprazole by the investigator) were each reported at a frequency of >1% in clinical trials for the risk-reduction of gastric ulcers; arthralgia, arthrosis, aggravated rheumatoid arthritis, cramps, myalgia, rash, urticaria, dizziness, headache, neuropathy, insomnia, constipation, duodenitis, epigastric pain, gastric mucosal lesion NOS, mucosal discoloration GI, esophageal disorder, esophagitis, vomiting, dry mouth, increased AST, increased ALT, bronchitis, coughing, dyspnoea, pharyngitis, respiratory infection, sinusitis, anemia, thrombocythemia, micturation frequency, urinary tract infection, benign GI neoplasm, accident/or injury, back pain, chest pain, fatigue, peripheral edema, pain, and postoperative complications.

In addition, the following adverse events of a potentially severe nature (considered unrelated to esomeprazole by the investigator) were reported in these same studies; cardiac failure, hypertension/hypertension aggravated, tachycardia, palpitation, atrial fibrillation, extrasystoles, bradycardia, arrhythmia, myocardial fibrosis, coronary artery disorder, syncope, thrombocytopenia, leucopenia, and cholelithiasis.

In an open label, 12 month clinical study conducted in 21 patients with either Zollinger-Ellison syndrome or idiopathic hypersecretion, single cases of the following adverse events, not previously listed under other indications, were reported with NEXIUM use, irrespective of causality: abdominal rigidity, asthma, Barrett's esophagus, carcinoid tumour of the stomach, carpal tunnel syndrome, depression, erosive gastritis, gingival abscess, hematuria, hyperparathyroidism, hypoesthesia, hypokalemia, hypomagnesemia, hypothyroidism, mean cell volume decreased, melena, muscle spasms, neoplasm progression, osteoporosis, parathesia, pharyngolaryngeal pain, postoperative pain, proteinuria, pruritus, rhinorrhea.

dermatitis, pruritus and urticaria.

paresthesia.

malaise.

hyponatremia.

muscular weakness.

hepatic encephalopathy.

See Adverse Reactions, Post-market Adverse Drug Reactions, and Warnings and Precautions, Carcinogenesis and Mutagenesis.

From post-marketing experience there have been uncommon reports (<1%) of peripheral edema, insomnia, paresthesia, somnolence, vertigo, increased liver enzymes.

There have been rare reports (<0.1%) of blurred vision, hypersensitivity reactions (e.g. angioedema, anaphylactic reaction/shock), myalgia, leukopenia, thrombocytopenia, depression, alopecia, hepatitis with or without jaundice, hyponatremia, agitation, confusion, taste disturbance, bronchospasm, stomatitis, GI candidiasis, rash, dermatitis photosensitivity, arthralgia, malaise, and hyperhidrosis.

Very rarely (<0.01%) agranulocytosis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, pancytopenia, aggression, hallucination, hepatic failure, hepatic encephalopathy, intestinal nephritis, muscular weakness and gynecomastia have been reported.

Esomeprazole magnesium is metabolized by the cytochrome P-450 system (CYP), mainly in the liver, through CYP 2C19 and CYP 3A4. There are no clinically significant interactions between esomeprazole and diazepam, phenytoin, warfarin, quinidine or cisapride{†No longer marketed in Canada.}.

With on-demand therapy, the implications for interactions with other pharmaceuticals, due to fluctuating plasma concentrations of esomeprazole, should be considered when NEXIUM is prescribed in this manner (see Dosage and Administration).

Concomitant administration of NEXIUM (30 mg once daily for 5 days) resulted in a 45% decrease in the clearance of diazepam in healthy male volunteers. Studies in females have not been conducted. Increased levels of diazepam were seen some 12 hours after dosing and later when the plasma levels of diazepam were below its therapeutic range. Therefore, this interaction is unlikely to be of clinical significance.

Concomitant administration of 40 mg NEXIUM (once daily for 3 weeks) to male and female patients on stable anticoagulation therapy with warfarin, resulted in a 13% increase in trough plasma levels of R-warfarin (the less potent enantiomer) while that of S-warfarin was unchanged. Coagulation times were stable throughout the entire study period. No clinically significant interaction was observed. However, from post marketed use, cases of elevated international normalized ratio (INR) of clinical significance have been reported during concomitant treatment with warfarin. Close monitoring is recommended when initiating and ending treatment with warfarin or other coumarin derivatives (please refer to approved Product Monograph for warfarin or relevant coumarin derivative).

Concomitant administration of 40 mg NEXIUM (once daily for 2 weeks) to male and female epileptic patients stabilized on phenytoin, resulted in a 13% increase in trough plasma levels of phenytoin. This minor interaction is unlikely to be of clinical relevance as dose reduction was not required in any patient nor was the profile and frequency of adverse events affected.

Results from a range of interaction studies with NEXIUM versus other drugs indicate that daily doses of 40 mg NEXIUM, given for 5 to 21 days in male and/or female subjects, has no clinically relevant interactions with CYP 1A2 (caffeine), CYP 2C9 (S-warfarin), and CYP 3A (quinidine, estradiol and cisapride†).

Concomitant administration of esomeprazole may reduce the plasma levels of atazanavir.

Concomitant administration of esomeprazole with a combined inhibitor of CYP 2C19 and CYP 3A4 may result in more than double the levels of esomeprazole exposure.

As with all drugs that reduce gastric acidity, changes in plasma levels of other drugs whose absorption is pH dependent (e.g. ketoconazole or itraconazole) must be taken into account when they are co-administered with esomeprazole.

Food intake delays and decreases the absorption of esomeprazole although this has no significant influence on the effect of esomeprazole on intragastric acidity.

As demonstrated with other PPIs, prolonged use may impair the absorption of protein-bound Vitamin B₁₂ and may contribute to the development of Vitamin B₁₂ deficiency.

• The tablets should be swallowed whole with sufficient water.

  
  

• The tablets may also be dispersed in half a glass of non-carbonated water. No other liquids should be used as the enteric coating may be dissolved. Stir until the tablets disintegrate and drink the liquid with the pellets immediately or within 30 minutes. Rinse the glass with half a glass of water and drink. The pellets must not be chewed or crushed.

  
  

• Dispersed tablets can also be administered via naso-gastric feeding tubes (8-20 French) using a 25 to 60 mL disposable syringe. The type of syringe used should ensure a secure fit with the feeding tube. Each NEXIUM tablet should be dispersed in 50 mL of water and passed through the tube into the stomach. After administering the suspension, the naso-gastric tube may be flushed with an additional 25-50 mL of water to clear the syringe and tube. In larger naso-gastric feeding tubes (i.e. 14 French or larger), the dispersion volume may be reduced to 25 mL.

  
  

The recommended adult dose in patients with reflux esophagitis is 40 mg NEXIUM once daily for 4 to 8 weeks in order to optimize the healing rate and symptom resolution. Healing occurs in the majority of patients within 4 weeks. Sustained freedom from symptoms is achieved rapidly for most patients. An additional 4 weeks of treatment is recommended for patients in whom esophagitis has not healed or who have persistent symptoms.

For the long-term treatment of patients whose reflux esophagitis has been healed with acid suppression therapy, the recommended adult dose is 20 mg NEXIUM once daily. Controlled studies do not extend beyond 6 months.

In patients with heartburn and/or acid regurgitation, without esophagitis, the recommended adult dose is 20 mg NEXIUM once daily for 2 to 4 weeks. If symptom control is not achieved after 4 weeks of treatment, further investigation is recommended.

For the maintenance of symptom relief in patients whose symptoms were initially controlled after daily doses for 2 to 4 weeks, the recommended adult dose is 20 mg NEXIUM once daily taken as needed. Despite treatment, the possibility for development of esophagitis in patients cannot be excluded.

In patients requiring NSAID therapy, the recommended dose is 20 mg NEXIUM once daily for 4 to 8 weeks. No additional clinical benefit was observed for the 40 mg dose over the 20 mg dose.

In patients requiring NSAID therapy who are at risk of gastric ulcers, the recommended dose is 20 mg NEXIUM once daily. No additional clinical benefit was observed for the 40 mg dose over the 20 mg dose. Controlled studies did not extend beyond 6 months.

The dosage in patients with pathological hypersecretory conditions varies with each individual. The recommended initial dosage is 40 mg NEXIUM twice a day. Dosages should then be adjusted to individual patient's needs and treatment should continue as long as clinically indicated. A small number of patients have been treated with doses up to 80 mg t.i.d. In a clinical study, 90% of patients (19 out of 21) with a hypersecretory condition such as Zollinger-Ellison syndrome had gastric acid outputs appropriately controlled at various doses and were maintained through 12 months. Safety information is limited in doses above 80 mg a day.

The recommended dose is NEXIUM 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg, all twice daily for seven days. No further treatment with NEXIUM is required to ensure healing and/or symptom control. This dosing regimen can also be known as NEXIUM 1-2-3 A.

The recommended dose is NEXIUM 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg, all twice daily for seven days. This dosing regimen can also be known as NEXIUM 1-2-3 A. Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

A missed dose should be taken as soon as possible within 12 hours. If more than 12 hours have passed, then the next scheduled dose should be taken at the appropriate time.

When used in combination with amoxicillin and clarithromycin, please refer to the Product Monographs of these drugs for prescribing information regarding Contraindications, Warnings and Dosing (in elderly and patients with renal and hepatic insufficiency).

No dose adjustment is required (see Warnings and Precautions).

No dose adjustment is required for patients with mild to moderate hepatic impairment. The daily doses of 20 mg in patients with severe hepatic impairment should not, as a rule, be exceeded (see Warnings and Precautions).

No dose adjustment is required (see Warnings and Precautions).