Esomeprazole

Registered South African indications:

• Gastro-oesophageal reflux disease (GORD)
  - Treatment of erosive reflux oesophagitis
  - Long-term management of patients with healed oesophagitis to prevent relapse
  - Symptomatic treatment of gastro-oesophageal reflux disease (GORD)
• Patients requiring continued non-steroidal anti-inflammatory drug (NSAID) therapy (tab)
  - Prevention of gastric and duodenal ulcers associated with NSAID therapy in patients at risk
• In combination with appropriate antibacterial therapeutic regimens for the eradication of Helicobacter pylori (tab)
  - Healing of Helicobacter pylori associated duodenal ulcer
  - Prevention of relapse of peptic ulcers in patients with Helicobacter pylori associated ulcer disease

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Esomeprazole has been used in pathological hypersecretory conditions including Zollinger-Ellison syndrome and idiopathic hypersecretion (tab)

Registered South African contraindications

• Hypersensitivity to the active ingredient or any of its excipients
• Hypersensitivity to substituted benzimidazoles
• Coadministration with atazanavir and nelfinavir

South African recommendations

Caution in the following patient groups

• Pregnancy
• Breastfeeding
• Severe renal impairment
• Severe hepatic impairment
• Elderly

Granules for oral suspension

Mild gastrointestinal complaints

• Esomeprazole as is not indicated for mild gastrointestinal complaints such as nervous dyspepsia

Malignancy

• Prior to treatment or in the presence of any alarm symptom (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, the possibility of malignancy of gastric ulcer or a malignant disease of the oesophagus should be excluded as the treatment with esomeprazole may alleviate the symptoms of malignant ulcers and can thus delay diagnosis

Long treatment

• Patients on long-term treatment (particularly those treated for more than a year) should be kept under regular surveillance

Chromogranin A (CgA) increase

• During treatment with antisecretory medicines, serum gastrin increases in response to the decreased acid secretion. Also, chromogranin A (CgA) increase due to decreased gastric acidity
• The increased CgA level may interfere with investigations for neuroendocrine tumours. To avoid this interference, the esomeprazole treatment should be temporarily stopped 5 days before CgA measurements
• If CgA and gastrin levels have not returned to the reference range after initial measurement, measurements should be repeated 14 days after cessation of proton pump inhibitor treatment

Gastrointestinal infections

• Decreased gastric acidity increases gastric contents counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to increased risk of gastrointestinal infections such as Salmonella and Campylobacter and, in hospitalised patients, possibly also Clostridium difficile
• Clostridium difficile is a bacterium that can cause severe debilitating diarrhoea that does not improve. Symptoms may include watery stools, abdominal pain, fever, and patients may develop more serious intestinal conditions

Subacute cutaneous lupus erythematosus (SCLE)

• Proton pump inhibitors are associated with very infrequent cases of subacute cutaneous lupus erythematosus (SCLE)
• If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care practitioner should consider stopping esomeprazole
• SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors

Risk of interstitial nephritis

• Interstitial nephritis has been reported on patience treated with esomeprazole. Interstitial nephritis may progress to acute kidney injury and/or chronic renal failure even after esomeprazole treatment discontinuation

Helicobacter pylori eradication

• When prescribing esomeprazole for eradication of Helicobacter pylori possible drug interactions for all components in the triple therapy should be considered
• Clarithromycin is a potent inhibitor of CYP3A4 and hence contraindications and interactions for clarithromycin should be considered when triple therapy is used in patients concurrently taking other medicines metabolised via CYP3A4, such as cisapride

Absorption of vitamin B₁₂

• Esomeprazole, as all acid-blocking medicines, may reduce the absorption of vitamin B₁₂ (cyanocobalamin) due to hypo- or achlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy

Hypomagnesaemia

• Severe hypomagnesaemia has been reported in patients treated with proton pump inhibitors (PPIs) like esomeprazole for at least three months, and in most cases for a year
• Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur, but they may begin insidiously and be overlooked. In most affected patients, hypomagnesaemia improved after magnesium replacement and discontinuation of the esomeprazole
• For patients expected to be on prolonged treatment or who take PPIs with digoxin or medicinal products that may cause hypomagnesaemia (e.g. diuretics), healthcare professionals should consider measuring magnesium levels before starting PPI treatment and periodically during treatment

Risk of fractures

• Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors
• Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10-40%. Some of this increase may be due to other risk factors
• Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium

Serious cutaneous adverse reactions (SCARs)

• Serious cutaneous adverse reactions (SCARs) such as erythema multiforme (EM), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS), which can be life-threatening, have been reported very rarely in association with esomeprazole treatment
• Patients should be advised of the signs and symptoms of the severe skin reaction EM/SJS/TEN/DRESS and should seek medical advice from their physician immediately when observing any indicative signs or symptoms
• Esomeprazole should be discontinued immediately upon signs and symptoms of severe skin reactions and additional medical care/close monitoring should be provided as needed. Re-challenge should not be undertaken in patients with EM/SJS/TEN/DRESS

Excipients with known effect

• Esomeprazole contains sucrose and dextrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take esomeprazole. Esomeprazole granules may be harmful to the teeth

Effects on ability to drive and use machines

• Esomeprazole may cause dizziness and blurred vision, thereby affecting the ability to drive or use machinery

Gastro-resistant tablets

Mild gastrointestinal complaints

• Esomeprazole as is not indicated for mild gastrointestinal complaints such as nervous dyspepsia

Malignancy

• In the presence of any alarm symptom (such as significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded, as treatment with esomeprazole may alleviate symptoms and delay diagnosis

Long treatment

• Regular monitoring of patients on long-term treatment (particularly those treated for more than a year) is recommended

Acute tubulointerstitial nephritis

• Acute interstitial nephritis (AIN)/acute tubulointerstitial nephritis has been observed in patients taking PPIs, such as esomeprazole, and may occur at any point during PPI therapy. Acute tubulointerstitial nephritis is characterised by an inflammatory reaction within the tubulointerstitial space of the kidney. Acute interstitial inflammatory reactions are associated with damage to the tubulointerstitium, leading to acute kidney injury (acute renal failure)
• Tubulointerstitial nephritis may be medicine-related, infectious, systemic, autoimmune, genetic, and idiopathic with the most common cause being related to a medication or medicine exposure. The risk of tubulointerstitial nephritis leading to chronic inflammation and reduced renal function associated with the use of protein pump inhibitors such as esomeprazole, is a class effect. Patients may present with non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). A delay in diagnosis and continued use of esomeprazole could lead to chronic kidney failure
• Healthcare professionals should frequently monitor renal function and check urine for haematuria and/or proteinuria. Patients should be advised to report any decrease in urine volumes or suspect that there is blood in their urine. Treatment with esomeprazole should be discontinued in patients with acute interstitial nephritis

Gastrointestinal infections

• Esomeprazole reduces gastric acidity which may increase gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with esomeprazole may lead to increased risk of gastrointestinal infections such as Salmonella and Campylobacter and also Clostridium difficile in hospitalised patients
• Clostridium difficile is a bacterium that can cause severe debilitating diarrhoea that does not improve. Symptoms may include watery stools, abdominal pain, fever, and patients may develop more serious intestinal conditions

Hypergastrinaemia

• Hypergastrinaemia may occur during treatment with esomeprazole

Vitamin absorption

• Esomeprazole may reduce the absorption of some vitamins such as vitamin B₁₂ (cyanocobalamin) due to hypo- or achlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B₁₂ absorption on long-term therapy

Risk of fractures

• Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors
• Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10-40%. Some of this increase may be due to other risk factors
• Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium

False-negative results

• Treatment with esomeprazole may cause false-negative results in the urea breath test for Helicobacter pylori infection

Coadministration with warfarin

• Prothrombin time and international normalised ratio (INR) should be monitored for increases in patients receiving esomeprazole and warfarin concurrently

On-demand therapy

• Patients on on-demand treatment should be instructed to contact their healthcare provider if their symptoms change in character
• When prescribing esomeprazole for on-demand therapy, the implications for interactions with other medicines, due to fluctuating plasma concentrations of esomeprazole, should be considered

Hypomagnesaemia

• Severe hypomagnesaemia has been reported in patients treated with proton pump inhibitors (PPIs) like esomeprazole for at least three months, and in most cases for a year
• Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular dysrhythmia can occur but they may begin insidiously and be overlooked. In most affected patients, hypomagnesaemia improved after magnesium replacement and discontinuation of the PPI
• For patients expected to be on prolonged treatment or who take esomeprazole with digoxin or medicines that may cause hypomagnesaemia (e.g. diuretics), healthcare providers should consider measuring magnesium levels before starting esomeprazole treatment and periodically during treatment

CYP2C19 inhibition

• Esomeprazole is a CYP2C19 inhibitor. When starting or ending treatment with esomeprazole, the potential for interactions with medicines metabolised through CYP2C19 should be considered. An interaction is observed between clopidogrel and esomeprazole
• Concomitant administration of clopidogrel and esomeprazole resulted in decreased exposure of the active metabolite of clopidogrel by an average of 40%. The maximum inhibition of (ADP induced) platelet aggregation decreased by an average of 14%. As a precaution, concomitant use of esomeprazole and clopidogrel should be discouraged

Subacute cutaneous lupus erythematosus (SCLE)

• Proton pump inhibitors, such as esomeprazole, are associated with very infrequent cases of subacute cutaneous lupus erythematosus (SCLE). If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the healthcare provider should consider stopping esomeprazole
• SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors

Chromogranin A (CgA) increase

• During treatment with antisecretory medicines, serum gastrin increases in response to the decreased acid secretion. Also chromogranin A (CgA) increase due to decreased gastric acidity. Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours
• To avoid this interference, esomeprazole treatment should be stopped for at least 5 days before CgA measurements. If CgA and gastrin levels have not returned to reference range after initial measurement, measurements should be repeated 14 days after cessation of esomeprazole treatment

Excipient warnings

• Esomeprazole contains sucrose and lactose. Patients with rare hereditary conditions such as fructose and/or galactose intolerance e.g. galactosaemia, Lapp lactase deficiency, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take esomeprazole

Effects on ability to drive and use machines

• Esomeprazole can cause side effects, such as blurred vision and dizziness
• Caution is advised before driving a vehicle or operating machinery or performing any tasks that require concentration, until the effects of esomeprazole are known

Forms avail. in SA and covered in this monograph: gra, fct, tab

South African registered indications and dosages

Gastro-oesophageal reflux disease (GORD)
- Treatment of erosive reflux oesophagitis

• Oral (fct, tab): 40mg, once daily; Treatment duration: 4 weeks; An additional 4 weeks treatment is recommended for patients in whom oesophagitis has not healed, or who have persistent symptoms

- Long-term management of patients with healed oesophagitis to prevent relapse

• Oral (fct, tab): 20mg, once daily

- Symptomatic treatment of gastro-oesophageal reflux disease (GORD)

• Oral (fct, tab): 20mg, once daily in patients without oesophagitis; If symptom control has not been achieved after 4 weeks, the patients should be further investigated; Once symptoms have resolved, subsequent symptom control can be achieved using an on-demand regimen: 20mg, once daily, when needed

Patients requiring continued non-steroidal anti-inflammatory drug (NSAID) therapy
- Prevention of gastric and duodenal ulcers associated with NSAID therapy in patients at risk

• Oral (fct, tab): 20mg or 40mg, once daily

In combination with appropriate antibacterial therapeutic regimens for the eradication of Helicobacter pylori
- Healing of Helicobacter pylori associated duodenal ulcer
- Prevention of relapse of peptic ulcers in patients with Helicobacter pylori associated ulcer disease

• Oral (fct, tab): 20mg, omeprazole with 1g amoxicillin and 500mg clarithromycin, twice daily; Treatment duration: 7 days

Pathological hypersecretory conditions including Zollinger-Ellison syndrome and idiopathic hypersecretion

• Oral (fct, tab): Initial: 40mg, twice daily; Then adjust dose individually and treatment should be continued as long as clinically indicated; Doses up to 120mg, twice daily have been administered

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Method of administration (tablets):
Esomeprazole tablets should be swallowed whole with liquid. The tablets should not be chewed or crushed. The tablets can also be dispersed in half a glass of non-carbonated water. No other liquids may be used. Stir until the tablets disintegrate and drink the liquid with the 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. For patients who cannot swallow the tablets, the tablets can be dispersed in non-carbonated water and administered through a gastric tube

Paed. forms avail. in SA and covered in this monograph: gra, fct, tab

South African registered indications and dosages

Gastro-oesophageal reflux disease (GORD)
- Treatment of erosive reflux oesophagitis

Children under 1 year

• Not established for use

Children between 1-11 years

• Oral (gra): <20kg: Recommended dose: 10mg, once daily; Treatment duration: 8 weeks
• Oral (gra): ≥20kg: Recommended dose: 10-20mg, once daily; Treatment duration: 8 weeks

Adolescents between 12-18 years

• See adult dosage (fct, tab)

- Symptomatic treatment of Gastro-oesophageal reflux disease (GORD)

Children under 1 year

• Not established for use

Children between 1-11 years

• Oral (gra): Recommended dose: 10mg, once daily; Treatment duration: 8 weeks

Adolescents between 12-18 years

• See adult dosage (fct, tab)

- Long-term management of patients with healed oesophagitis to prevent relapse

Children under 1 year

• Not established for use

Children between 1-11 years

• Oral (gra): Recommended dose: 10mg, once daily

Adolescents between 12-18 years

• See adult dosage (fct, tab)

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Esomeprazole granules should not be used in children less than a year old since no data is available
The safety and efficacy of esomeprazole tablets in children younger than 12 years of age has not been established. No data is available

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Doses over 1mg/kg have not been studied (gra)

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Method of administration (granules):
For oral use. The contents of the 10mg sachet should be emptied into a container containing a tablespoon (15ml) of water. Stir the contents and leave for a few minutes to thicken. Stir again and drink within 30 minutes. If any material remains after drinking, add more water, stir, and drink immediately
For patients who have a nasogastric or gastric tube in place, the contents of the sachet can be added to a syringe containing 15ml of water. Immediately shake the syringe and leave for a few minutes to thicken. Shake the syringe and inject through the nasogastric or gastric tube within 30 minutes. Refill the syringe with an equal amount of water and shake and flush any remaining contents from the nasogastric or gastric tube into the stomach

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Method of administration (tablets):
Esomeprazole tablets should be swallowed whole with liquid. The tablets should not be chewed or crushed. The tablets can also be dispersed in half a glass of non-carbonated water. No other liquids may be used. Stir until the tablets disintegrate and drink the liquid with the 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. For patients who cannot swallow the tablets, the tablets can be dispersed in non-carbonated water and administered through a gastric tube

Pregnancy

South African recommendations

Granules for oral suspension

• Caution
• Safety during pregnancy has not been established

Gastro-resistant tablets

• Caution
• Safety during pregnancy has not been established
• Clinical data on exposed pregnancies with esomeprazole are insufficient. With the racemic mixture omeprazole data on a larger number of exposed pregnancies from epidemiological studies indicate no malformative nor foetotoxic effect
• Animal studies with esomeprazole do not indicate direct or indirect harmful effects with respect to embryonal/foetal development. Animal studies with the racemic mixture do not indicate direct or indirect harmful effects with respect to pregnancy, parturition or postnatal development
• Caution should be exercised when prescribing to pregnant women. A moderate amount of data on pregnant women (between 300-1000 pregnancy outcomes) indicates no malformative or foeto/neonatal toxicity of esomeprazole. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity

Breastfeeding

South African recommendations

Granules for oral suspension

• Caution
• Safety during lactation has not been established

Gastro-resistant tablets

• Caution; not recommended
• It is not known whether esomeprazole is excreted in human breast milk. There is insufficient information on the effects of esomeprazole in newborns/infants
• Esomeprazole should not be used during breastfeeding

Fertility

South African recommendations

Granules for oral suspension

• No information available

Gastro-resistant tablets

• Animal studies with the racemic mixture omeprazole, given by oral administration do not indicate effects with respect to fertility

South African recommendations

• Mild to moderate: No dose adjustment recommended
• Severe: Caution; no dose adjustment recommended
  Use with caution in patients with severe renal insufficiency due to limited experience in these patients

South African recommendations

• Mild to moderate: No dose adjustment recommended
• Severe: Caution; dose adjustment recommended
  Max. daily dose: 20mg

South African recommendations

• Caution; no dose adjustment recommended
  Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors

Blood and Lymphatic System Disorders

Less frequent

• Leukopenia
• Thrombocytopenia
• Agranulocytosis
• Pancytopenia

Immune System Disorders

Less frequent

• Hypersensitivity reactions e.g. angioedema, bronchospasm 
• Anaphylactic reaction/shock

Metabolism and Nutrition Disorders

Less frequent

• Hyponatraemia
• Hypomagnesaemia
  - Severe hypomagnesaemia may result in hypocalcaemia, hypomagnesaemia may also result in hypokalaemia

Psychiatric Disorders

Less frequent

• Insomnia
• Somnolence
• Agitation
• Confusion
• Depression
• Aggression
• Hallucinations 

Nervous System Disorders

Frequent

• Headache

Less frequent

• Dizziness
• Paraesthesia

Eye Disorders

Less frequent

• Blurred vision
• Eye disorders

Ear and Labyrinth Disorders

Less frequent

• Vertigo
• Tinnitus

Cardiac Disorders

Less frequent

• Angina
• Tachycardia
• Bradycardia

Respiratory, Thoracic and Mediastinal Disorders

Less frequent

• Respiratory infection
• Sinusitis
• Cough

Gastrointestinal Disorders

Frequent

• Abdominal pain
• Diarrhoea
• Flatulence
• Nausea/vomiting
• Constipation
• Dyspepsia

Less frequent

• Dry mouth
• Taste disturbance
• Stomatitis
• Gastrointestinal candidiasis
• Pancreatitis
• Fundic gland polyps (benign)
• Gastrointestinal infections
• Microscopic colitis

Hepato-Biliary Disorders

Less frequent

• Increased liver enzymes
• Hepatitis
• Jaundice
• Hepatic encephalopathy
• Hepatic failure

Skin and Subcutaneous Tissue Disorders

Frequent

• Rash

Less frequent

• Dermatitis
• Pruritus
• Urticaria
• Alopecia
• Photosensitivity
• Bullous eruption
• Increased sweating
• Drug reaction with eosinophilia and systemic symptoms (DRESS)
• Erythema multiforme
• Stevens-Johnson syndrome
• Toxic epidermal necrolysis (TEN)
• Subacute cutaneous lupus erythematosus (SCLE)

Musculoskeletal, Connective Tissue and Bone Disorders

Less frequent

• Back pain
• Arthralgia
• Myalgia
• Musclar weakness
• Myopathy
• Fracture of the hip, wrist or spine

Renal and Urinary Disorders

Less frequent

• Acute interstitial nephritis/acute tubulointerstitial nephritis (which could lead to acute kidney injury and/or chronic renal failure)
• Urinary disorders

Reproductive System and Breast Disorders

Less frequent

• Gynaecomastia
• Impotence

General Disorders and Administration Site Conditions

Less frequent

• Fever
• Peripheral oedema
• Malaise
• Fatigue

• Atazanavir
• Nelfinavir
• Clopidogrel
• Saquinavir
• Tipranavir
• Medicines with a gastric pH dependent absorption
• Ketoconazole
• Itraconazole
• Erlotinib
• Digoxin
• Diazepam
• Citalopram
• Imipramine
• Clomipramine
• Phenytoin
• Warfarin
• Cilostazol
• High dose methotrexate
• Tacrolimus
• CYP3A4 inhibitors
• Clarithromycin
• CYP2C19 inhibitors
• Voriconazole
• CYP2C19 inducers
• CYP3A4 inducers
• Rifampicin

Other interactions

• St. John's Wort
• Vitamin B₁₂ (absorption affected)
• Interference with laboratory tests
  - Investigations for neuroendocrine tumours, see Warnings and Precautions

None routine. Specific cases may require

• Renal function
  - Check urine for haematuria and/or proteinuria
• Serum magnesium levels
• Digoxin levels (when coadministered)
• Prothrombin time and international normalised ratio (when coadministered with warfarin)
• Plasma concentrations of phenytoin (when coadministered)
• Tacrolimus concentrations (when coadministered)

Additional observations

• Symptoms and signs of fracture
  - Assess osteoporosis risk especially with long-term therapy
• Signs and symptoms of severe skin reactions

Esomeprazole is the S-isomer of omeprazole. Omeprazole consists of both R- and S-isomers which have similar pharmacodynamic activities. Esomeprazole reduces gastric acid secretion through the specific inhibition of the enzyme H⁺,K⁺-ATPase, which is the acid pump in the parietal cells of the stomach. It accumulates in the acidic secretory canaliculi where it is concentrated, converted into the active form and inhibits both basal and stimulated acid secretion. The activated form irreversibly inactivates the pump molecule, and acid secretion only resumes after new pump molecules are synthesised, which provides prolonged suppression of acid secretion.

Tablet 20mg

• Esotab 20mg (Forrester Pharma)
• Nectizole (Abex)
• Nesopram (Ranbaxy)
• Nexiflux (Abex)
• Nexipraz (Ranbaxy)
• Nexiam (AstraZeneca) originator
• Nexmezol (Sandoz)
• Nexomep (Sandoz)
• Trustan (Pharmacare Limited)

Tablet 40mg

• Esotab 40mg (Forrester Pharma)
• Mitogut 40 (Dr Reddy's)
• Nectizole (Abex)
• Nesopram (Ranbaxy Pharmaceuticals)
• Nexiflux (Abex)
• Nexipraz (Ranbaxy Pharmaceuticals)
• Nexiam (AstraZeneca) originator
• Nexmezol (Sandoz)
• Nexomep (Sandoz)
• Trustan (Pharmacare Limited)

Sachet 2.5mg

• Nexiam (AstraZeneca) originator

Sachet 5mg

• Nexiam (AstraZeneca) originator

Sachet 10mg

• Nexiam (AstraZeneca) originator

Injection (per vial) 40mg

• Aspepraz (Pharmacare)
• Nexiam (AstraZeneca) originator
• Nexipraz (Ranbaxy Pharmaceuticals)
• Truloc IV 40mg (Pharma Dynamics)

COMBINATION PREPARATIONS

Naproxen/ Esomeprazole

Tablet 500mg/20mg

• Vimovo (AstraZeneca) originator