Esomeprazole

Esomeprazole is a proton pump inhibitor (PPI) used to reduce gastric acid secretion.

It is the S-enantiomer of omeprazole and is prescribed for gastro-oesophageal reflux disease (GORD), the healing and maintenance of erosive oesophagitis, peptic ulcer disease, Zollinger-Ellison syndrome, and in combination with antibiotics for Helicobacter pylori eradication.

Esomeprazole irreversibly inhibits the hydrogen-potassium ATPase enzyme (proton pump) on the parietal cells of the stomach.

This blocks the final common pathway of acid secretion, producing a more profound and longer-lasting reduction in gastric acidity than H2-receptor antagonists.

Clinical Use

Esomeprazole is widely regarded as one of the most effective PPIs, achieving consistently high rates of symptom relief and mucosal healing in GORD and erosive oesophagitis.

It is also used prophylactically to prevent NSAID-associated gastric and duodenal ulceration in patients requiring long-term anti-inflammatory treatment.

Short-term use is well established as safe and effective.

The risk-benefit ratio of long-term use should be assessed regularly, as prolonged acid suppression is associated with certain potential complications.

How to Take Esomeprazole

Swallow the tablet whole with water, at least one hour before a meal, preferably in the morning.

Do not chew or crush the tablet, as this destroys the enteric coating that protects the drug from stomach acid.

If You Cannot Swallow Tablets

The tablet can be dispersed in half a glass of still water (not milk or carbonated drinks), stirred gently, and the suspension drunk within 30 minutes.

Rinse the glass with water and drink the rinse to ensure the full dose is taken.

Duration

For reflux symptoms: usually 4-8 weeks. For maintenance: the lowest effective dose. For H. pylori eradication: 7-14 days alongside antibiotics.

GORD (Symptomatic Treatment)

• 20 mg once daily for 4 weeks (extend to 8 weeks if not healed)

Erosive Oesophagitis (Healing)

• 40 mg once daily for 4-8 weeks

Erosive Oesophagitis (Maintenance)

• 20 mg once daily

H. pylori Eradication

• 20 mg twice daily for 7 days (with two antibiotics as per local guidelines)

NSAID-Associated Ulcer Prophylaxis

• 20 mg once daily

Zollinger-Ellison Syndrome

• Starting dose 40 mg twice daily; titrate to response

Renal Impairment

• No dose adjustment

Hepatic Impairment

• Severe: do not exceed 20 mg daily

Common (up to 1 in 10 patients)

• Headache
• Abdominal pain, diarrhoea, flatulence, nausea, or constipation

Uncommon (up to 1 in 100 patients)

• Dizziness
• Dry mouth
• Skin rash or dermatitis
• Peripheral oedema

Rare (up to 1 in 1,000 patients)

• Leucopenia, thrombocytopenia
• Hepatitis (with or without jaundice)
• Arthralgia and myalgia
• Blurred vision

Very Rare (fewer than 1 in 10,000 patients)

• Interstitial nephritis
• Stevens-Johnson syndrome or toxic epidermal necrolysis
• Hypomagnesaemia (with prolonged use)
• Pancytopenia or agranulocytosis

Long-Term Use Concerns

• Increased risk of Clostridioides difficile infection
• Possible small increase in hip, wrist, and spine fracture risk
• Reduced vitamin B12 and magnesium absorption

Long-Term Use

Prolonged PPI use (beyond 8 weeks) should be reviewed regularly. Long-term acid suppression is associated with a modest increase in the risk of C.

difficile infection, bone fractures, hypomagnesaemia, and vitamin B12 deficiency. Use the lowest effective dose for the shortest duration.

Exclude Malignancy

Esomeprazole can mask the symptoms of gastric carcinoma.

When alarm features are present (unintended weight loss, dysphagia, vomiting, anaemia), endoscopy should be performed before starting PPI therapy.

Magnesium Monitoring

For patients on long-term treatment, consider periodic serum magnesium checks, especially if also taking diuretics or digoxin.

Drug Interactions

Esomeprazole reduces absorption of drugs requiring an acidic gastric environment (e.g., ketoconazole, erlotinib, iron salts).

It inhibits CYP2C19 and may increase levels of diazepam, citalopram, and phenytoin.

Do not take esomeprazole if you have:

• A known hypersensitivity to esomeprazole, any other PPI (omeprazole, lansoprazole, pantoprazole, rabeprazole), or any excipient
• Concurrent use with nelfinavir (HIV protease inhibitor — plasma levels are significantly reduced)

Use with caution in severe hepatic impairment (dose reduction required).