<?xml version="1.0" encoding="UTF-8"?><title>These highlights do not include all the information needed to use NEXIUM safely and effectively. See full prescribing information for NEXIUM.<br/> <br/>NEXIUM^® (esomeprazole magnesium) delayed-release capsules, for oral use <br/>NEXIUM^® (esomeprazole magnesium) for delayed-release oral suspension<br/>Initial U.S. Approval: 1989 (omeprazole)</title>

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<?xml version="1.0" encoding="UTF-8"?><section ID="ID_c7ffae3d-658f-4db2-aa5d-80cebf48c3df"> <id root="680abcc0-ed06-499d-8f3f-5a4614b486d9"/> <code code="43683-2" codeSystem="2.16.840.1.113883.6.1" displayName="RECENT MAJOR CHANGES SECTION"/> <effectiveTime value="20180607"/> <excerpt> <highlight> <text> <paragraph/> <list listType="ordered"> <item> <caption> </caption>Warnings and Precautions, Fundic Gland Polyps <linkHtml href="#ID_de20c6c5-b74b-4584-8269-7fd7c150b3bb">(5.12)</linkHtml> 06/2018</item> </list> </text> </highlight> </excerpt> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1158778506850"> <id root="89495996-6a58-4d4d-bf22-b05f82e20e87"/> <code code="34067-9" codeSystem="2.16.840.1.113883.6.1" displayName="INDICATIONS &amp; USAGE SECTION"/> <title>1 INDICATIONS AND USAGE</title> <effectiveTime value="20180607"/> <excerpt> <highlight> <text> <paragraph>NEXIUM is a proton pump inhibitor indicated for the following:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Treatment of gastroesophageal reflux disease (GERD). <linkHtml href="#ID_404054bd-cf3b-4dcd-804d-ad7544263617">(1.1)</linkHtml> </item> <item> <caption>•</caption>Risk reduction of NSAID-associated gastric ulcer. <linkHtml href="#ID_97fb7468-5cd1-4718-8130-3f766740d17a">(1.2)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="italics">H. pylori </content>eradication to reduce the risk of duodenal ulcer recurrence. <linkHtml href="#ID_04bd52d5-5138-4e52-8162-3d3e8df6b934">(1.3)</linkHtml> </item> <item> <caption>•</caption>Pathological hypersecretory conditions, including Zollinger-Ellison syndrome. <linkHtml href="#ID_9d3b8789-5f4c-484a-9bf6-167dda8ad9bb">(1.4)</linkHtml> </item> </list> </text> </highlight> </excerpt> <component> <section ID="ID_404054bd-cf3b-4dcd-804d-ad7544263617"> <id root="fb686c2c-3c6c-4ee2-bee5-ed9ef3e730cb"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>1.1 Treatment of Gastroesophageal Reflux Disease (GERD)</title> <text> <paragraph> <content styleCode="italics">Healing of Erosive Esophagitis</content> </paragraph> <paragraph>NEXIUM is indicated for the short-term treatment (4 to 8 weeks) in the healing and symptomatic resolution of diagnostically confirmed erosive esophagitis. For those patients who have not healed after 4 to 8 weeks of treatment, an additional 4 to 8 week course of NEXIUM may be considered.</paragraph> <paragraph>In infants 1 month to less than 1 year, NEXIUM is indicated for short-term treatment (up to 6 weeks) of erosive esophagitis due to acid-mediated GERD.</paragraph> <paragraph> <content styleCode="italics">Maintenance of Healing of Erosive Esophagitis</content> </paragraph> <paragraph>NEXIUM is indicated to maintain symptom resolution and healing of erosive esophagitis. Controlled studies do not extend beyond 6 months.</paragraph> <paragraph> <content styleCode="italics">Symptomatic Gastroesophageal Reflux Disease </content> </paragraph> <paragraph>NEXIUM is indicated for short-term treatment (4 to 8 weeks) of heartburn and other symptoms associated with GERD in adults and children 1 year or older. </paragraph> </text> <effectiveTime value="20141219"/> </section> </component> <component> <section ID="ID_97fb7468-5cd1-4718-8130-3f766740d17a"> <id root="e3d0ea23-75ec-4912-a477-02a32e70952a"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>1.2 Risk Reduction of NSAID-Associated Gastric Ulcer</title> <text> <paragraph>NEXIUM is indicated for the reduction in the occurrence of gastric ulcers associated with continuous NSAID therapy in patients at risk for developing gastric ulcers. Patients are considered to be at risk due to their age (≥ 60) and/or documented history of gastric ulcers. Controlled studies do not extend beyond 6 months.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> <component> <section ID="ID_04bd52d5-5138-4e52-8162-3d3e8df6b934"> <id root="be4f664c-2aa4-42d4-9a72-320d21de876a"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>1.3 <content styleCode="italics">H. pylori</content> Eradication to Reduce the Risk of Duodenal Ulcer Recurrence</title> <text> <paragraph>Triple Therapy (NEXIUM plus amoxicillin and clarithromycin): NEXIUM, in combination with amoxicillin and clarithromycin, is indicated for the treatment of patients with <content styleCode="italics">H. pylori</content> infection and duodenal ulcer disease (active or history of within the past 5 years) to eradicate <content styleCode="italics">H. pylori</content>. Eradication of <content styleCode="italics">H. pylori</content> has been shown to reduce the risk of duodenal ulcer recurrence <content styleCode="italics">[see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml> and <linkHtml href="#williamsonbk1158778492663">Clinical Studies (14)</linkHtml>]</content>.</paragraph> <paragraph>In patients who fail therapy, susceptibility testing should be done. If resistance to clarithromycin is demonstrated or susceptibility testing is not possible, alternative antimicrobial therapy should be instituted <content styleCode="italics">[see <linkHtml href="#williamsonbk1158777874678">Clinical Pharmacology (12.4)</linkHtml> and the prescribing information for clarithromycin]</content>.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_9d3b8789-5f4c-484a-9bf6-167dda8ad9bb"> <id root="ef04e002-07dc-40ed-9a80-d95b7622a425"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>1.4 Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome</title> <text> <paragraph>NEXIUM is indicated for the long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison Syndrome.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1158841553901"> <id root="238fe707-6109-4ce7-a24e-65927f5b6f0d"/> <code code="34068-7" codeSystem="2.16.840.1.113883.6.1" displayName="DOSAGE &amp; ADMINISTRATION SECTION"/> <title>2 DOSAGE AND ADMINISTRATION</title> <text> <paragraph>NEXIUM is supplied as delayed-release capsules for oral administration or in packets for preparation of delayed-release oral suspensions. The recommended dosages are outlined in Table 1. NEXIUM should be taken at least one hour before meals.</paragraph> <paragraph>The duration of proton pump inhibitor administration should be based on available safety and efficacy data specific to the defined indication and dosing frequency, as described in the prescribing information, and individual patient medical needs. Proton pump inhibitor treatment should only be initiated and continued if the benefits outweigh the risks of treatment.</paragraph> <table width="100%"> <caption>Table 1: Recommended Dosage Schedule for NEXIUM</caption> <col width="62%"/> <col width="13%"/> <col width="25%"/> <tbody> <tr> <td styleCode="Toprule " valign="top"> <paragraph>Indication</paragraph> </td> <td styleCode="Toprule " valign="top"> <paragraph>Dose</paragraph> </td> <td styleCode="Toprule " valign="top"> <paragraph>Frequency</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold">Gastroesophageal Reflux Disease (GERD)</content> </paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>Healing of Erosive Esophagitis</item> </list> </td> <td valign="top"> <paragraph>20 mg or 40 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 4 to 8 Weeks<footnote ID="_Ref437951533"> <content styleCode="italics">[See <linkHtml href="#ID_3d75d1b4-e7af-436e-acbb-186ac7f49f16">Clinical Studies (14.1)</linkHtml>]</content> The majority of patients are healed within 4 to 8 weeks. For patients who do not heal after 4 to 8 weeks, an additional 4 to 8 weeks of treatment may be considered.</footnote> </paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>Maintenance of Healing of Erosive Esophagitis </item> </list> </td> <td valign="top"> <paragraph>20 mg </paragraph> </td> <td valign="top"> <paragraph>Once Daily<footnote ID="_Ref1977">Controlled studies did not extend beyond six months.</footnote> </paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>Symptomatic Gastroesophageal Reflux Disease</item> </list> </td> <td valign="top"> <paragraph>20 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 4 Weeks<footnote ID="_Ref437952378">If symptoms do not resolve completely after 4 weeks, an additional 4 weeks of treatment may be considered.</footnote> </paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold">Pediatric GERD</content> </paragraph> <paragraph> <content styleCode="bold">12 to 17 Year Olds</content> </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>Healing of Erosive Esophagitis</paragraph> <paragraph>Symptomatic GERD</paragraph> </td> <td valign="top"> <paragraph>20 mg or 40 mg</paragraph> <paragraph>20 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 4 to 8 Weeks</paragraph> <paragraph>Once Daily for 4 Weeks</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold">1 to 11 Year Olds</content> <footnote ID="_Ref437952431">Doses over 1 mg/kg/day have not been studied.</footnote> </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>Short-term Treatment of Symptomatic GERD</paragraph> </td> <td valign="top"> <paragraph>10 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for up to 8 Weeks</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph>Healing of Erosive Esophagitis</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="ordered"> <item> <caption> </caption> weight &lt; 20 kg </item> </list> </td> <td valign="top"> <paragraph>10 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 8 Weeks</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="ordered"> <item> <caption> </caption> weight ≥ 20 kg</item> </list> </td> <td valign="top"> <paragraph>10 mg or 20 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 8 Weeks</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph> <content styleCode="bold">1 month to &lt; 1 year old</content> <footnote ID="_Ref448329389">Doses over 1.33 mg/kg/day have not been studied.</footnote> </paragraph> </td> <td valign="top"/> <td valign="top"/> </tr> <tr> <td valign="top"> <paragraph>Erosive Esophagitis due to acid-mediated GERD</paragraph> </td> <td valign="top"/> <td valign="top"/> </tr> <tr> <td valign="top"> <list listType="ordered"> <item> <caption> </caption> weight 3 kg to 5 kg</item> </list> </td> <td valign="top"> <paragraph>2.5 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for up to 6 Weeks</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="ordered"> <item> <caption> </caption> weight &gt; 5 kg to 7.5 kg</item> </list> </td> <td valign="top"> <paragraph>5 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for up to 6 Weeks</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="ordered"> <item> <caption> </caption> weight &gt; 7.5 kg to 12 kg</item> </list> </td> <td valign="top"> <paragraph>10 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for up to 6 Weeks</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption> <content styleCode="bold">Risk Reduction of NSAID-Associated Gastric Ulcer</content> </item> </list> </td> <td valign="top"> <paragraph>20 mg or 40 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for up to 6 months<footnoteRef IDREF="_Ref1977"/> </paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold"> <content styleCode="italics">H. pylori </content> Eradication to Reduce the Risk of Duodenal Ulcer Recurrence</content> </paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption> <content styleCode="italics">Triple Therapy:</content> </item> </list> </td> <td valign="top"/> <td valign="top"/> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>NEXIUM</item> </list> </td> <td valign="top"> <paragraph>40 mg</paragraph> </td> <td valign="top"> <paragraph>Once Daily for 10 Days</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>Amoxicillin</item> </list> </td> <td valign="top"> <paragraph>1000 mg</paragraph> </td> <td valign="top"> <paragraph>Twice Daily for 10 Days</paragraph> </td> </tr> <tr> <td valign="top"> <list listType="unordered"> <item> <caption> </caption>Clarithromycin</item> </list> </td> <td valign="top"> <paragraph>500 mg</paragraph> </td> <td valign="top"> <paragraph>Twice Daily for 10 Days</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"> <paragraph> <content styleCode="bold">Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome</content> </paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>40 mg<footnote ID="_Ref2024">The dosage of NEXIUM in patients with pathological hypersecretory conditions varies with the individual patient. Dosage regimens should be adjusted to individual patient needs.</footnote> </paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Twice Daily<footnote ID="_Ref439934010">Doses up to 240 mg daily have been administered <content styleCode="italics">[see <linkHtml href="#williamsonbk1184875345638">Drug Interactions (7)</linkHtml>]</content>.</footnote> </paragraph> </td> </tr> </tbody> </table> <paragraph>Please refer to amoxicillin and clarithromycin prescribing information for Contraindications, Warnings, and dosing in elderly and renally-impaired patients.</paragraph> <paragraph> <content styleCode="bold">Specific Populations</content> </paragraph> <paragraph> <content styleCode="italics">Hepatic Insufficiency</content> </paragraph> <paragraph>In patients with mild to moderate liver impairment (Child‑Pugh Classes A and B), no dosage adjustment is necessary. For patients with severe liver impairment (Child‑Pugh Class C), a dose of 20 mg of NEXIUM should not be exceeded <content styleCode="italics">[see <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml>]</content>.</paragraph> <paragraph>Directions for use specific to the route and available methods of administration for each of these dosage forms are presented in Table 2.</paragraph> <table width="100%"> <caption>Table 2: Administration Options</caption> <col width="18%"/> <col width="15%"/> <col width="67%"/> <tbody> <tr> <td align="center" colspan="3" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold">Administration Options </content> </paragraph> <paragraph> <content styleCode="bold">(See text following table for additional instructions.)</content> </paragraph> </td> </tr> <tr> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">Dosage Form</content> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">Route</content> </paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">Options</content> </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Delayed-Release Capsules</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Oral</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>Capsule can be swallowed whole.</paragraph> <paragraph>-or-</paragraph> <paragraph> Capsule can be opened and mixed with applesauce.</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Delayed-Release Capsules</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Nasogastric Tube</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>Capsule can be opened and the intact granules emptied into a syringe and delivered through the nasogastric tube.</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>For Delayed-Release Oral Suspension</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Oral </paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>For the 2.5 mg and 5 mg strengths, mix the contents of packet with 5 mL of water, leave 2 to 3 minutes to thicken, stir and drink within 30 minutes. </paragraph> <paragraph>For the 10 mg, 20 mg and 40 mg strengths, mix contents of packet with 15 mL of water, and follow the instructions above.</paragraph> </td> </tr> <tr> <td styleCode="Botrule Lrule " valign="top"> <paragraph>For Delayed-Release Oral Suspension</paragraph> </td> <td styleCode="Botrule Lrule " valign="top"> <paragraph>Nasogastric or Gastric Tube</paragraph> </td> <td styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>For the 2.5 mg and 5 mg strengths, add 5 mL of water to a syringe and then add contents of packet. Shake the syringe; leave 2 to 3 minutes to thicken. Shake the syringe and inject through the nasogastric or gastric tube within 30 minutes. </paragraph> <paragraph>For the 10 mg, 20 mg and 40 mg strengths, add 15 mL of water, and follow the instructions above.</paragraph> </td> </tr> </tbody> </table> <paragraph> <content styleCode="underline">NEXIUM Delayed-Release Capsules</content> </paragraph> <paragraph>NEXIUM Delayed-Release Capsules should be swallowed whole.</paragraph> <paragraph>Alternatively, for patients who have difficulty swallowing capsules, one tablespoon of applesauce can be added to an empty bowl and the NEXIUM Delayed-Release Capsule can be opened, and the granules inside the capsule carefully emptied onto the applesauce. The granules should be mixed with the applesauce and then swallowed immediately: do not store for future use. The applesauce used should not be hot and should be soft enough to be swallowed without chewing. The granules should not be chewed or crushed. If the granules/applesauce mixture is not used in its entirety, the remaining mixture should be discarded immediately.</paragraph> <paragraph>For patients who have a nasogastric tube in place, NEXIUM Delayed-Release Capsules can be opened and the intact granules emptied into a 60 mL catheter tipped syringe and mixed with 50 mL of water. It is important to only use a catheter tipped syringe when administering NEXIUM through a nasogastric tube. Replace the plunger and shake the syringe vigorously for 15 seconds. Hold the syringe with the tip up and check for granules remaining in the tip. Attach the syringe to a nasogastric tube and deliver the contents of the syringe through the nasogastric tube into the stomach. After administering the granules, the nasogastric tube should be flushed with additional water. Do not administer the granules if they have dissolved or disintegrated. </paragraph> <paragraph>The mixture must be used immediately after preparation.</paragraph> <paragraph> <content styleCode="underline">NEXIUM For Delayed-Release Oral Suspension </content> </paragraph> <paragraph>NEXIUM For Delayed-Release Oral Suspension should be administered as follows:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Empty the contents of a 2.5 mg or 5 mg packet into a container containing 5 mL of water. For the 10 mg, 20 mg, and 40 mg strengths, the contents of a packet should be emptied into a container containing 15 mL of water.</item> <item> <caption>•</caption>Stir.</item> <item> <caption>•</caption>Leave 2 to 3 minutes to thicken. </item> <item> <caption>•</caption>Stir and drink within 30 minutes.</item> <item> <caption>•</caption>If any medicine remains after drinking, add more water, stir, and drink immediately.</item> <item> <caption>•</caption>In cases where there is a need to use two packets, they may be mixed in a similar way by adding twice the required amount of water or follow the mixing instructions provided by your pharmacist or doctor.</item> </list> <paragraph>For patients who have a nasogastric or gastric tube in place, NEXIUM For Delayed-Release Oral Suspension can be administered as follows:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Add 5 mL of water to a catheter tipped syringe and then add the contents of a 2.5 mg or 5 mg NEXIUM packet. For the 10 mg, 20 mg, and 40 mg strengths, the volume of water in the syringe should be 15 mL. It is important to only use a catheter tipped syringe when administering NEXIUM through a nasogastric tube or gastric tube.</item> <item> <caption>•</caption>Immediately shake the syringe and leave 2 to 3 minutes to thicken.</item> <item> <caption>•</caption>Shake the syringe and inject through the nasogastric or gastric tube, French size 6 or larger, into the stomach within 30 minutes.</item> <item> <caption>•</caption>Refill the syringe with an equal amount of water (5 mL or 15 mL).</item> <item> <caption>•</caption>Shake and flush any remaining contents from the nasogastric or gastric tube into the stomach.</item> </list> </text> <effectiveTime value="20161220"/> <excerpt> <highlight> <text> <table width="100%"> <col width="28%"/> <col width="26%"/> <col width="46%"/> <thead> <tr> <th align="left" styleCode="Botrule Toprule " valign="top"> <content styleCode="bold">Indication</content> </th> <th align="left" styleCode="Botrule Toprule " valign="top"> <content styleCode="bold">Dose</content> </th> <th align="left" styleCode="Botrule Toprule " valign="top"> <content styleCode="bold">Frequency</content> </th> </tr> </thead> <tbody> <tr> <td colspan="3" styleCode="Toprule " valign="top"> <paragraph> <content styleCode="bold">Gastroesophageal Reflux Disease (GERD)</content> </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>Adults</paragraph> </td> <td valign="top"> <paragraph>20 mg or 40 mg</paragraph> </td> <td valign="top"> <paragraph>Once daily for 4 to 8 weeks</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>12 to 17 years </paragraph> </td> <td valign="top"> <paragraph>20 mg or 40 mg </paragraph> </td> <td valign="top"> <paragraph>Once daily for up to 8 weeks</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>1 to 11 years</paragraph> </td> <td valign="top"> <paragraph>10 mg or 20 mg</paragraph> </td> <td valign="top"> <paragraph>Once daily for up to 8 weeks</paragraph> </td> </tr> <tr> <td colspan="3" styleCode="Botrule " valign="top"> <paragraph>1 month to less than 1 year: 2.5 mg, 5 mg or 10 mg (based on weight). Once daily, up to 6 weeks for erosive esophagitis (EE) due to acid-mediated GERD only.</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold">Risk Reduction of NSAID-Associated Gastric Ulcer</content> </paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td styleCode="Botrule " valign="top"> <paragraph>20 mg or 40 mg</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Once daily for up to 6 months</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold"> <content styleCode="italics">H. pylori</content> Eradication</content> <content styleCode="italics"> (Triple Therapy):</content> </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>NEXIUM</paragraph> </td> <td valign="top"> <paragraph>40 mg</paragraph> </td> <td valign="top"> <paragraph>Once daily for 10 days</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>Amoxicillin</paragraph> </td> <td valign="top"> <paragraph>1000 mg</paragraph> </td> <td valign="top"> <paragraph>Twice daily for 10 days</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"> <paragraph>Clarithromycin</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>500 mg</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Twice daily for 10 days</paragraph> </td> </tr> <tr> <td colspan="3" valign="top"> <paragraph> <content styleCode="bold">Pathological Hypersecretory Conditions</content> </paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td styleCode="Botrule " valign="top"> <paragraph>40 mg </paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Twice daily</paragraph> </td> </tr> </tbody> </table> <paragraph>See full prescribing information for administration options. <linkHtml href="#williamsonbk1158841553901">(2)</linkHtml> </paragraph> <paragraph>Patients with severe liver impairment-do not exceed dose of 20 mg. <linkHtml href="#williamsonbk1158841553901">(2)</linkHtml> </paragraph> </text> </highlight> </excerpt> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_59bb139b-5ec4-4085-aeed-35601801af63"> <id root="43830031-53f4-477f-84f2-208629da5258"/> <code code="43678-2" codeSystem="2.16.840.1.113883.6.1" displayName="DOSAGE FORMS &amp; STRENGTHS SECTION"/> <title>3 DOSAGE FORMS AND STRENGTHS </title> <text> <paragraph>NEXIUM Delayed-Release Capsules, 20 mg - opaque, hard gelatin, amethyst colored capsules with two radial bars in yellow on the cap and NEXIUM 20 mg in yellow on the body.</paragraph> <paragraph>NEXIUM Delayed-Release Capsules, 40 mg - opaque, hard gelatin, amethyst colored capsules with three radial bars in yellow on the cap and NEXIUM 40 mg in yellow on the body.</paragraph> <paragraph>NEXIUM For Delayed-Release Oral Suspension, 2.5 mg, 5 mg, 10 mg, 20 mg or 40 mg - unit dose packet containing a fine yellow powder, consisting of white to pale brownish esomeprazole granules and pale yellow inactive granules.</paragraph> </text> <effectiveTime value="20141219"/> <excerpt> <highlight> <text> <list listType="unordered"> <item> <caption>•</caption>NEXIUM Delayed-Release Capsules: 20 mg and 40 mg. (<linkHtml href="#ID_59bb139b-5ec4-4085-aeed-35601801af63">3</linkHtml>)</item> <item> <caption>•</caption>NEXIUM For Delayed-Release Oral Suspension: 2.5 mg, 5 mg, 10 mg, 20 mg, and 40 mg. (<linkHtml href="#ID_59bb139b-5ec4-4085-aeed-35601801af63">3</linkHtml>)</item> </list> </text> </highlight> </excerpt> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1158777746710"> <id root="57bcbd04-2c7c-4537-badc-05dc5cbc9759"/> <code code="34070-3" codeSystem="2.16.840.1.113883.6.1" displayName="CONTRAINDICATIONS SECTION"/> <title>4 CONTRAINDICATIONS</title> <text> <paragraph>NEXIUM is contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute interstitial nephritis, and urticaria <content styleCode="italics">[see <linkHtml href="#ID_e487a007-d2fe-465f-ab81-b945d816d173">Adverse Reactions (6)</linkHtml>]</content>.</paragraph> <paragraph>For information about contraindications of antibacterial agents (clarithromycin and amoxicillin) indicated in combination with NEXIUM, refer to the CONTRAINDICATIONS section of their package inserts.</paragraph> </text> <effectiveTime value="20161220"/> <excerpt> <highlight> <text> <paragraph>Patients with known hypersensitivity to proton pump inhibitors (PPIs) (angioedema and anaphylaxis have occurred). <linkHtml href="#williamsonbk1158777746710">(4)</linkHtml> </paragraph> </text> </highlight> </excerpt> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1168525520489"> <id root="ff74a667-c9c7-4d0c-a2bb-b0abd612d7f5"/> <code code="43685-7" codeSystem="2.16.840.1.113883.6.1" displayName="WARNINGS AND PRECAUTIONS SECTION"/> <title>5 WARNINGS AND PRECAUTIONS</title> <effectiveTime value="20180607"/> <excerpt> <highlight> <text> <list listType="unordered"> <item> <caption>•</caption> <content styleCode="underline">Gastric Malignancy:</content> In adults, symptomatic response does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing. <linkHtml href="#ID_718ffed2-5591-47ff-adee-3a6873fcf7fe">(5.1)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Acute Interstitial Nephritis</content>: Observed in patients taking PPIs. <linkHtml href="#ID_adf7e4c9-9f73-40ac-baad-06bc92770930">(5.2)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline"> <content styleCode="italics">Clostridium difficile-</content>Associated Diarrhea:</content> PPI therapy may be associated with increased risk. <linkHtml href="#ID_6b0e1800-d077-49ac-851c-d3422efeaa8f">(5.3)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Bone Fracture:</content> Long-term and multiple daily dose PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist or spine. <linkHtml href="#williamsonbk1282066915764">(5.4)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Cutaneous and Systemic Lupus Erythematosus:</content> Mostly cutaneous; new onset or exacerbation of existing disease; discontinue NEXIUM and refer to specialist for evaluation. <linkHtml href="#ID_9c98abad-7d2d-45c4-9b79-952629467d42">(5.5)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Interaction with Clopidogrel:</content> Avoid concomitant use of NEXIUM. <linkHtml href="#ID_4ebf6a2e-4775-4204-8a3b-66223a98b493">(5.6)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Cyanocobalamin (Vitamin B-12) Deficiency: </content>Daily long-term use (e.g., longer than 3 years) may lead to malabsorption or a deficiency of cyanocobalamin. <linkHtml href="#ID_b13ac510-713a-4b92-b387-61a7d97aefd7">(5.7)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Hypomagnesemia:</content> Reported rarely with prolonged treatment with PPIs. <linkHtml href="#ID_99eafb44-c0ea-451c-9dba-722cfeaf9050">(5.8)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Interaction with St. John’s Wort or Rifampin:</content> Avoid concomitant use of NEXIUM. <linkHtml href="#williamsonbk1310048381585">(5.9</linkHtml>, <linkHtml href="#williamsonbk1310047508742">7.3)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Interactions with Diagnostic Investigations for Neuroendocrine Tumors:</content> Increased chromogranin A (CgA) levels may interfere with diagnostic investigations for neuroendocrine tumors, temporarily stop NEXIUM at least 14 days before assessing CgA levels. <linkHtml href="#ID_5b766617-0025-47db-9f43-e99bb2b62604">(5.10</linkHtml>, <linkHtml href="#williamsonbk1310048423179">12.2)</linkHtml> </item> <item> <caption>•</caption> <content styleCode="underline">Interaction with Methotrexate</content>: Concomitant use with PPIs may elevate and/or prolong serum concentrations of methotrexate and/or its metabolite, possibly leading to toxicity. With high dose methotrexate administration, consider temporary withdrawal of NEXIUM. <linkHtml href="#williamsonbk1327936497308">(5.11</linkHtml>, <linkHtml href="#williamsonbk1327936521605">7.7)</linkHtml> </item> <item> <caption>•</caption>Fundic Gland Polyps: Risk increases with long-term use, especially beyond one year. Use the shortest duration of therapy. <linkHtml href="#ID_de20c6c5-b74b-4584-8269-7fd7c150b3bb">(5.12) </linkHtml> </item> </list> </text> </highlight> </excerpt> <component> <section ID="ID_718ffed2-5591-47ff-adee-3a6873fcf7fe"> <id root="5cfbf593-71d1-429f-8343-a3e6c415be96"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.1 Presence of Gastric Malignancy</title> <text> <paragraph>In adults, symptomatic response to therapy with NEXIUM does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.</paragraph> </text> <effectiveTime value="20160714"/> </section> </component> <component> <section ID="ID_adf7e4c9-9f73-40ac-baad-06bc92770930"> <id root="ee35ca5f-90c2-4c07-b12d-4d4cd364a403"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.2 Acute Interstitial Nephritis</title> <text> <paragraph>Acute interstitial nephritis has been observed in patients taking PPIs including NEXIUM. Acute interstitial nephritis may occur at any point during PPI therapy and is generally attributed to an idiopathic hypersensitivity reaction. Discontinue NEXIUM if acute interstitial nephritis develops <content styleCode="italics">[see <linkHtml href="#williamsonbk1158777746710">Contraindications (4)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_6b0e1800-d077-49ac-851c-d3422efeaa8f"> <id root="8edf14b3-b26c-4a9a-b883-b60b4e98524c"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.3 <content styleCode="italics">Clostridium difficile-</content>Associated Diarrhea </title> <text> <paragraph>Published observational studies suggest that PPI therapy like NEXIUM may be associated with an increased risk of <content styleCode="italics">Clostridium difficile-</content>associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve <content styleCode="italics">[see <linkHtml href="#ID_36bfd923-1437-491d-9487-ae5a769721c3">Adverse Reactions (6.2)</linkHtml>]</content>. </paragraph> <paragraph>Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. </paragraph> <paragraph> <content styleCode="italics">Clostridium difficile-</content>associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents. For more information specific to antibacterial agents (clarithromycin and amoxicillin) indicated for use in combination with NEXIUM, refer to Warnings and Precautions section of the corresponding prescribing information. </paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="williamsonbk1282066915764"> <id root="9d31ff4a-f37e-4955-be18-ab58fe167932"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.4 Bone Fracture</title> <text> <paragraph>Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines <content styleCode="italics">[see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml> and <linkHtml href="#ID_36bfd923-1437-491d-9487-ae5a769721c3">Adverse Reactions (6.2)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_9c98abad-7d2d-45c4-9b79-952629467d42"> <id root="c90cfafd-8d4e-42c5-883c-99eba3c717c0"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.5 Cutaneous and Systemic Lupus Erythematosus </title> <text> <paragraph>Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including esomeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematosus cases were CLE.</paragraph> <paragraph>The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement.</paragraph> <paragraph>Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported.</paragraph> <paragraph>Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving NEXIUM, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g., ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.</paragraph> </text> <effectiveTime value="20171027"/> </section> </component> <component> <section ID="ID_4ebf6a2e-4775-4204-8a3b-66223a98b493"> <id root="8b159f90-c2d1-4dce-ae5e-51dcd27d00ce"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.6 Interaction with Clopidogrel</title> <text> <paragraph>Avoid concomitant use of NEXIUM with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as esomeprazole, that inhibit CYP2C19 activity. Concomitant use of clopidogrel with 40 mg esomeprazole reduces the pharmacological activity of clopidogrel. When using NEXIUM consider alternative anti-platelet therapy <content styleCode="italics">[see <linkHtml href="#williamsonbk1310047508742">Drug Interactions (7.3)</linkHtml> and <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_b13ac510-713a-4b92-b387-61a7d97aefd7"> <id root="8c8bb2f0-337f-4abf-8152-008e9804d2c8"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.7 Cyanocobalamin (Vitamin B-12) Deficiency </title> <text> <paragraph>Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B-12) caused by hypo- or achlorhydria. Rare reports of cyanocobalamin deficiency occurring with acid-suppressing therapy have been reported in the literature. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed.</paragraph> </text> <effectiveTime value="20160714"/> </section> </component> <component> <section ID="ID_99eafb44-c0ea-451c-9dba-722cfeaf9050"> <id root="9640a5ee-082a-4a71-a3e0-ace1b655509f"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.8 Hypomagnesemia</title> <text> <paragraph>Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI.</paragraph> <paragraph>For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically <content styleCode="italics">[see <linkHtml href="#ID_36bfd923-1437-491d-9487-ae5a769721c3">Adverse Reactions (6.2)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="williamsonbk1310048381585"> <id root="2c468ebe-7d32-4d35-b2f7-f7bc2c47762a"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.9 Interaction with St. John’s Wort or Rifampin</title> <text> <paragraph>Drugs which induce CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease esomeprazole concentrations <content styleCode="italics">[see <linkHtml href="#williamsonbk1310047508742">Drug Interactions (7.3)</linkHtml>]</content>. Avoid concomitant use of NEXIUM with St. John’s Wort or rifampin.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_5b766617-0025-47db-9f43-e99bb2b62604"> <id root="78043a37-6e03-4f8d-b0da-c7054c1adb08"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.10 Interactions with Diagnostic Investigations for Neuroendocrine Tumors</title> <text> <paragraph>Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g., for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary <content styleCode="italics">[see <linkHtml href="#williamsonbk1310048423179">Clinical Pharmacology (12.2)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="williamsonbk1327936497308"> <id root="361c546a-7d4a-4ac1-8f62-9e87780564bb"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>5.11 Interaction with Methotrexate</title> <text> <paragraph>Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration a temporary withdrawal of the PPI may be considered in some patients <content styleCode="italics">[see <linkHtml href="#williamsonbk1327936521605">Drug Interactions (7.7)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_de20c6c5-b74b-4584-8269-7fd7c150b3bb"> <id root="d09aac9f-3ca1-4582-a4f1-d09da98c7f07"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title> <content styleCode="xmChange">5.12 Fundic Gland Polyps</content> </title> <text> <paragraph> <content styleCode="xmChange">PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated.</content> </paragraph> </text> <effectiveTime value="20180607"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_e487a007-d2fe-465f-ab81-b945d816d173"> <id root="2e410cf6-0353-49de-a0d6-82ed7cce7b68"/> <code code="34084-4" codeSystem="2.16.840.1.113883.6.1" displayName="ADVERSE REACTIONS SECTION"/> <title>6 ADVERSE REACTIONS</title> <text> <paragraph>The following serious adverse reactions are described below and elsewhere in labeling:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Acute Interstitial Nephritis <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#ID_adf7e4c9-9f73-40ac-baad-06bc92770930">Warnings and Precautions (5.2)</linkHtml> </content> <content styleCode="italics">]</content> </item> <item> <caption>•</caption> <content styleCode="italics">Clostridium difficile-</content>Associated Diarrhea<content styleCode="italics"> [see </content> <content styleCode="italics"> <linkHtml href="#ID_6b0e1800-d077-49ac-851c-d3422efeaa8f">Warnings and Precautions (5.3)</linkHtml> </content> <content styleCode="italics">]</content> </item> <item> <caption>•</caption>Bone Fracture<content styleCode="italics"> [see </content> <content styleCode="italics"> <linkHtml href="#williamsonbk1282066915764">Warnings and Precautions (5.4)</linkHtml> </content> <content styleCode="italics">]</content> </item> <item> <caption>•</caption>Cutaneous and Systemic Lupus Erythematosus <content styleCode="italics">[see <linkHtml href="#ID_9c98abad-7d2d-45c4-9b79-952629467d42">Warnings and Precautions (5.5)</linkHtml>]</content> </item> <item> <caption>•</caption>Cyanocobalamin (Vitamin B-12) Deficiency <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#ID_b13ac510-713a-4b92-b387-61a7d97aefd7">Warnings and Precautions (5.7)</linkHtml> </content> <content styleCode="italics">]</content> </item> <item> <caption>•</caption>Hypomagnesemia<content styleCode="italics"> [see <linkHtml href="#ID_99eafb44-c0ea-451c-9dba-722cfeaf9050">Warnings and Precautions (5.8)</linkHtml>]</content> </item> <item> <caption>•</caption>Fundic Gland Polyps [see <content styleCode="italics"> <linkHtml href="#ID_de20c6c5-b74b-4584-8269-7fd7c150b3bb">Warnings and Precautions (5.12)</linkHtml> </content>]</item> </list> </text> <effectiveTime value="20180607"/> <excerpt> <highlight> <text> <paragraph/> <paragraph>Most common adverse reactions <linkHtml href="#williamsonbk1185474323706">(6.1)</linkHtml>:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Adults (≥ 18 years) (incidence <content styleCode="underline">&gt;</content>1%) are headache, diarrhea, nausea, flatulence, abdominal pain, constipation, and dry mouth. </item> <item> <caption>•</caption>Pediatric (1 to 17 years) (incidence <content styleCode="underline">&gt;</content>2%) are headache, diarrhea, abdominal pain, nausea, and somnolence. </item> <item> <caption>•</caption>Pediatric (1 month to less than 1 year) (incidence 1%) are abdominal pain, regurgitation, tachypnea, and increased ALT. </item> </list> <paragraph> <content styleCode="bold">To report SUSPECTED ADVERSE REACTIONS, contact AstraZeneca at 1-800-236-9933 or FDA at 1-800-FDA-1088 or <linkHtml href="http://www.fda.gov/medwatch">www.fda.gov/medwatch.</linkHtml> </content> </paragraph> </text> </highlight> </excerpt> <component> <section ID="williamsonbk1185474323706"> <id root="d40b4918-f9f3-43b7-86c2-135ce60e4900"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>6.1 Clinical Trials Experience</title> <text> <paragraph>Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.</paragraph> <paragraph> <content styleCode="bold">Adults</content> </paragraph> <paragraph>The safety of NEXIUM was evaluated in over 15,000 patients (aged 18 to 84 years) in clinical trials worldwide including over 8,500 patients in the United States and over 6,500 patients in Europe and Canada. Over 2,900 patients were treated in long-term studies for up to 6-12 months. In general, NEXIUM was well tolerated in both short and long-term clinical trials.</paragraph> <paragraph>The safety in the treatment of healing of erosive esophagitis was assessed in four randomized comparative clinical trials, which included 1,240 patients on NEXIUM 20 mg, 2,434 patients on NEXIUM 40 mg, and 3,008 patients on omeprazole 20 mg daily. The most frequently occurring adverse reactions (≥1%) in all three groups were headache (5.5, 5, and 3.8, respectively) and diarrhea (no difference among the three groups). Nausea, flatulence, abdominal pain, constipation, and dry mouth occurred at similar rates among patients taking NEXIUM or omeprazole.</paragraph> <paragraph>Additional adverse reactions that were reported as possibly or probably related to NEXIUM with an incidence &lt;1% are listed below by body system:</paragraph> <paragraph> <content styleCode="italics">Body as a Whole:</content> abdomen enlarged, allergic reaction, asthenia, back pain, chest pain, substernal chest pain, facial edema, peripheral edema, hot flushes, fatigue, fever, flu-like disorder, generalized edema, leg edema, malaise, pain, rigors; </paragraph> <paragraph> <content styleCode="italics">Cardiovascular:</content> flushing, hypertension, tachycardia; </paragraph> <paragraph> <content styleCode="italics">Endocrine:</content> goiter; </paragraph> <paragraph> <content styleCode="italics">Gastrointestinal:</content> bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting; </paragraph> <paragraph> <content styleCode="italics">Hearing:</content> earache, tinnitus; </paragraph> <paragraph> <content styleCode="italics">Hematologic:</content> anemia, anemia hypochromic, cervical lymphadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia;</paragraph> <paragraph> <content styleCode="italics">Hepatic:</content> bilirubinemia, hepatic function abnormal, SGOT increased, SGPT increased; </paragraph> <paragraph> <content styleCode="italics">Metabolic/Nutritional:</content> glycosuria, hyperuricemia, hyponatremia, increased alkaline phosphatase, thirst, vitamin B12 deficiency, weight increase, weight decrease; </paragraph> <paragraph> <content styleCode="italics">Musculoskeletal:</content> arthralgia, arthritis aggravated, arthropathy, cramps, fibromyalgia syndrome, hernia, polymyalgia rheumatica; </paragraph> <paragraph> <content styleCode="italics">Nervous System/Psychiatric:</content> anorexia, apathy, appetite increased, confusion, depression aggravated, dizziness, hypertonia, nervousness, hypoesthesia, impotence, insomnia, migraine, migraine aggravated, paresthesia, sleep disorder, somnolence, tremor, vertigo, visual field defect; </paragraph> <paragraph> <content styleCode="italics">Reproductive:</content> dysmenorrhea, menstrual disorder, vaginitis; </paragraph> <paragraph> <content styleCode="italics">Respiratory:</content> asthma aggravated, coughing, dyspnea, larynx edema, pharyngitis, rhinitis, sinusitis; </paragraph> <paragraph> <content styleCode="italics">Skin and Appendages:</content> acne, angioedema, dermatitis, pruritus, pruritus ani, rash, rash erythematous, rash maculo-papular, skin inflammation, sweating increased, urticaria; </paragraph> <paragraph> <content styleCode="italics">Special Senses:</content> otitis media, parosmia, taste loss, taste perversion; </paragraph> <paragraph> <content styleCode="italics">Urogenital: </content> abnormal urine, albuminuria, cystitis, dysuria, fungal infection, hematuria, micturition frequency, moniliasis, genital moniliasis, polyuria; </paragraph> <paragraph> <content styleCode="italics">Visual: </content> conjunctivitis, vision abnormal.</paragraph> <paragraph>The following potentially clinically significant laboratory changes in clinical trials, irrespective of relationship to NEXIUM, were reported in ≤1% of patients: increased creatinine, uric acid, total bilirubin, alkaline phosphatase, ALT, AST, hemoglobin, white blood cell count, platelets, serum gastrin, potassium, sodium, thyroxine and thyroid stimulating hormone <content styleCode="italics">[see <linkHtml href="#williamsonbk1158843286000">Clinical Pharmacology (12)</linkHtml>]</content>. Decreases were seen in hemoglobin, white blood cell count, platelets, potassium, sodium, and thyroxine.</paragraph> <paragraph>Endoscopic findings that were reported as adverse reactions include: duodenitis, esophagitis, esophageal stricture, esophageal ulceration, esophageal varices, gastric ulcer, gastritis, hernia, benign polyps or nodules, Barrett’s esophagus, and mucosal discoloration.</paragraph> <paragraph>The incidence of treatment-related adverse reactions during 6-month maintenance treatment was similar to placebo. There were no differences in types of related adverse reactions seen during maintenance treatment up to 12 months compared to short-term treatment.</paragraph> <paragraph>Two placebo-controlled studies were conducted in 710 patients for the treatment of symptomatic gastroesophageal reflux disease. The most common adverse reactions that were reported as possibly or probably related to NEXIUM were diarrhea (4.3%), headache (3.8%), and abdominal pain (3.8%).</paragraph> <paragraph> <content styleCode="bold">Pediatrics</content> </paragraph> <paragraph>The safety of NEXIUM was evaluated in 316 pediatric and adolescent patients aged 1 to 17 years in four clinical trials for the treatment of symptomatic GERD <content styleCode="italics">[see <linkHtml href="#williamsonbk1185473675741">Clinical Studies (14.2)</linkHtml>]</content>. In 109 pediatric patients aged 1 to 11 years, the most frequently reported (at least 1%) treatment-related adverse reactions in these patients were diarrhea (2.8%), headache (1.9%) and somnolence (1.9%). In 149 pediatric patients aged 12 to 17 years the most frequently reported (at least 2%) treatment-related adverse reactions in these patients were headache (8.1%), abdominal pain (2.7%), diarrhea (2%), and nausea (2%).</paragraph> <paragraph>The safety of NEXIUM was evaluated in 167 pediatric patients from birth to &lt;1 year of age in three clinical trials <content styleCode="italics">[see <linkHtml href="#williamsonbk1185378883110">Clinical Studies (14.3)</linkHtml>]</content>. In a study that included 26 pediatric patients aged birth to 1 month there were no treatment related adverse reactions. In a study that included 43 pediatric patients age 1 to 11 months, inclusive the most frequently reported (at least 5%) adverse reactions, irrespective of causality, were irritability and vomiting. In a study that included 98 pediatric patients, age 1 to 11 months, inclusive exposed to esomeprazole for up to 6 weeks (including 39 patients randomized to the withdrawal phase), there were 4 treatment-related adverse reactions: abdominal pain (1%), regurgitation (1%), tachypnea (1%), and increased ALT (1%).</paragraph> <paragraph>No new safety concerns were identified in pediatric patients.</paragraph> <paragraph> <content styleCode="bold">Combination Treatment with Amoxicillin and Clarithromycin </content> </paragraph> <paragraph>In clinical trials using combination therapy with NEXIUM plus amoxicillin and clarithromycin, no additional adverse reactions specific to these drug combinations were observed. Adverse reactions that occurred were limited to those observed when using NEXIUM, amoxicillin, or clarithromycin alone. </paragraph> <paragraph>The most frequently reported drug-related adverse reactions for patients who received triple therapy for 10 days were diarrhea (9.2%), taste perversion (6.6%), and abdominal pain (3.7%). No treatment-emergent adverse reactions were observed at higher rates with triple therapy than were observed with NEXIUM alone. </paragraph> <paragraph>For more information on adverse reactions with amoxicillin or clarithromycin, refer to their package inserts, Adverse Reactions sections. </paragraph> <paragraph>In clinical trials using combination therapy with NEXIUM plus amoxicillin and clarithromycin, no additional increased laboratory abnormalities particular to these drug combinations were observed. </paragraph> <paragraph>For more information on laboratory changes with amoxicillin or clarithromycin, refer to their package inserts, Adverse Reactions section.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_36bfd923-1437-491d-9487-ae5a769721c3"> <id root="3723b295-fa2e-46bf-924b-57c2d6002072"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>6.2 Postmarketing Experience</title> <text> <paragraph>The following adverse reactions have been identified during post-approval use of NEXIUM. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reports are listed below by body system:</paragraph> <paragraph> <content styleCode="italics">Blood and Lymphatic: </content> agranulocytosis, pancytopenia;</paragraph> <paragraph> <content styleCode="italics">Eye: </content>blurred vision;</paragraph> <paragraph> <content styleCode="italics">Gastrointestinal:</content> pancreatitis; stomatitis; microscopic colitis; fundic gland polyps;</paragraph> <paragraph> <content styleCode="italics">Hepatobiliary:</content> hepatic failure, hepatitis with or without jaundice; </paragraph> <paragraph> <content styleCode="italics">Immune System:</content> anaphylactic reaction/shock; systemic lupus erythematosus;</paragraph> <paragraph> <content styleCode="italics">Infections and Infestations:</content> GI candidiasis; <content styleCode="italics">Clostridium difficile-</content>associated diarrhea;</paragraph> <paragraph> <content styleCode="italics">Metabolism and nutritional disorders:</content> hypomagnesemia, with or without hypocalcemia and/or hypokalemia;</paragraph> <paragraph> <content styleCode="italics">Musculoskeletal and Connective Tissue:</content> muscular weakness, myalgia, bone fracture;</paragraph> <paragraph> <content styleCode="italics">Nervous System:</content> hepatic encephalopathy, taste disturbance; </paragraph> <paragraph> <content styleCode="italics">Psychiatric:</content> aggression, agitation, depression, hallucination; </paragraph> <paragraph> <content styleCode="italics">Renal and Urinary:</content> interstitial nephritis; </paragraph> <paragraph> <content styleCode="italics">Reproductive System and Breast:</content> gynecomastia; </paragraph> <paragraph> <content styleCode="italics">Respiratory, Thoracic, and Mediastinal:</content> bronchospasm; </paragraph> <paragraph> <content styleCode="italics">Skin and Subcutaneous Tissue:</content> alopecia, erythema multiforme, hyperhidrosis, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (some fatal), cutaneous lupus erythematosus.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1184875345638"> <id root="d33c4f28-ea90-48f7-b4e7-4d6781f227b9"/> <code code="34073-7" codeSystem="2.16.840.1.113883.6.1" displayName="DRUG INTERACTIONS SECTION"/> <title>7 DRUG INTERACTIONS</title> <effectiveTime value="20180607"/> <excerpt> <highlight> <text> <list listType="unordered"> <item> <caption>•</caption>May affect plasma levels of antiretroviral drugs – use with atazanavir and nelfinavir is not recommended; if saquinavir is used with NEXIUM, monitor for toxicity and consider saquinavir dose reduction. (<linkHtml href="#ID_88dd184a-fc0c-45f8-8f5d-ac9c96390c2b">7.1</linkHtml>)</item> <item> <caption>•</caption>May interfere with drugs for which gastric pH affects bioavailability (e.g., ketoconazole, iron salts, erlotinib, digoxin and mycophenolate mofetil). Patients treated with NEXIUM and digoxin may need to be monitored for digoxin toxicity. (<linkHtml href="#ID_e831c6a3-a06f-4acd-9946-d44bdd7e0df9">7.2</linkHtml>)</item> <item> <caption>•</caption>Combined inhibitor of CYP2C19 and 3A4 may raise esomeprazole levels. (<linkHtml href="#williamsonbk1310047508742">7.3</linkHtml>)</item> <item> <caption>•</caption>Clopidogrel: NEXIUM decreases exposure to the active metabolite of clopidogrel. (<linkHtml href="#williamsonbk1310047508742">7.3</linkHtml>)</item> <item> <caption>•</caption>May increase systemic exposure of cilostazol and an active metabolite. Consider dose reduction. (<linkHtml href="#williamsonbk1310047508742">7.3</linkHtml>)</item> <item> <caption>•</caption>Tacrolimus: NEXIUM may increase serum levels of tacrolimus. (<linkHtml href="#ID_be504ea1-eb95-4c98-bb94-4ed076f9078e">7.5</linkHtml>)</item> <item> <caption>•</caption>Methotrexate: NEXIUM may increase serum levels of methotrexate. (<linkHtml href="#williamsonbk1327936521605">7.7</linkHtml>)</item> </list> </text> </highlight> </excerpt> <component> <section ID="ID_88dd184a-fc0c-45f8-8f5d-ac9c96390c2b"> <id root="02de5ce7-82ad-4cba-9ab0-36f56ef0d909"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.1 Interference with Antiretroviral Therapy</title> <text> <paragraph>Concomitant use of atazanavir and nelfinavir with proton pump inhibitors is not recommended. Co-administration of atazanavir with proton pump inhibitors is expected to substantially decrease atazanavir plasma concentrations and may result in a loss of therapeutic effect and the development of drug resistance. Co-administration of saquinavir with proton pump inhibitors is expected to increase saquinavir concentrations, which may increase toxicity and require dose reduction. </paragraph> <paragraph>Omeprazole, of which esomeprazole is an enantiomer, has been reported to interact with some antiretroviral drugs. The clinical importance and the mechanisms behind these interactions are not always known. Increased gastric pH during omeprazole treatment may change the absorption of the antiretroviral drug. Other possible interaction mechanisms are via CYP2C19. </paragraph> <paragraph> <content styleCode="italics">Reduced concentrations of atazanavir and nelfinavir </content> </paragraph> <paragraph>For some antiretroviral drugs, such as atazanavir and nelfinavir, decreased serum levels have been reported when given together with omeprazole. Following multiple doses of nelfinavir (1250 mg, twice daily) and omeprazole (40 mg daily), AUC was decreased by 36% and 92%, C_max by 37% and 89% and C_min by 39% and 75% respectively for nelfinavir and M8. Following multiple doses of atazanavir (400 mg, daily) and omeprazole (40 mg, daily, 2 hours before atazanavir), AUC was decreased by 94%, C_max by 96%, and C_min by 95%. Concomitant administration with omeprazole and drugs such as atazanavir and nelfinavir is therefore not recommended. </paragraph> <paragraph> <content styleCode="italics">Increased concentrations of saquinavir</content> </paragraph> <paragraph>For other antiretroviral drugs, such as saquinavir, elevated serum levels have been reported, with an increase in AUC by 82%, in C_max by 75%, and in C_min by 106%, following multiple dosing of saquinavir/ritonavir (1000/100 mg) twice daily for 15 days with omeprazole 40 mg daily co-administered days 11 to 15. Therefore, clinical and laboratory monitoring for saquinavir toxicity is recommended during concurrent use with NEXIUM. Dose reduction of saquinavir should be considered from the safety perspective for individual patients. </paragraph> <paragraph>There are also some antiretroviral drugs of which unchanged serum levels have been reported when given with omeprazole.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_e831c6a3-a06f-4acd-9946-d44bdd7e0df9"> <id root="5d6fce4a-56cd-459f-b5b1-902c4a45885d"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.2 Drugs for Which Gastric pH Can Affect Bioavailability</title> <text> <paragraph>Due to its effects on gastric acid secretion, esomeprazole can reduce the absorption of drugs where gastric pH is an important determinant of their bioavailability. Like with other drugs that decrease the intragastric acidity, the absorption of drugs such as ketoconazole, atazanavir, iron salts, erlotinib, and mycophenolate mofetil (MMF) can decrease, while the absorption of drugs such as digoxin can increase during treatment with esomeprazole. Esomeprazole is an enantiomer of omeprazole. Concomitant treatment with omeprazole (20 mg daily) and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects). Co-administration of digoxin with NEXIUM is expected to increase the systemic exposure of digoxin. Therefore, patients may need to be monitored when digoxin is taken concomitantly with NEXIUM.</paragraph> <paragraph>Co-administration of omeprazole in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving NEXIUM and MMF. Use NEXIUM with caution in transplant patients receiving MMF <content styleCode="italics">[see <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="williamsonbk1310047508742"> <id root="0fd8cc74-b780-4225-b628-e98238880f3e"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.3 Effects on Hepatic Metabolism/Cytochrome P-450 Pathways</title> <text> <paragraph>Esomeprazole is extensively metabolized in the liver by CYP2C19 and CYP3A4. <content styleCode="italics">In vitro</content> and <content styleCode="italics">in vivo</content> studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1, and 3A4. No clinically relevant interactions with drugs metabolized by these CYP enzymes would be expected. Drug interaction studies have shown that esomeprazole does not have any clinically significant interactions with phenytoin, warfarin, quinidine, clarithromycin, or amoxicillin. </paragraph> <paragraph>However, postmarketing reports of changes in prothrombin measures have been received among patients on concomitant warfarin and esomeprazole therapy. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. Patients treated with proton pump inhibitors and warfarin concomitantly may need to be monitored for increases in INR and prothrombin time. </paragraph> <paragraph>Esomeprazole may potentially interfere with CYP2C19, the major esomeprazole metabolizing enzyme. Co-administration of esomeprazole 30 mg and diazepam, a CYP2C19 substrate, resulted in a 45% decrease in clearance of diazepam. </paragraph> <paragraph>Clopidogrel</paragraph> <paragraph>Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of esomeprazole 40 mg results in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition. Avoid concomitant administration of NEXIUM with clopidogrel. When using NEXIUM, consider use of alternative anti-platelet therapy <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml> </content> <content styleCode="italics">]</content>.</paragraph> <paragraph>Omeprazole acts as an inhibitor of CYP2C19. Omeprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in cross-over study, increased C_max and AUC of cilostazol by 18% and 26% respectively. C_max and AUC of one of its active metabolites, 3,4-dihydrocilostazol, which has 4-7 times the activity of cilostazol, were increased by 29% and 69%, respectively. Co-administration of cilostazol with esomeprazole is expected to increase concentrations of cilostazol and its above mentioned active metabolite. Therefore, a dose reduction of cilostazol from 100 mg twice daily to 50 mg twice daily should be considered.</paragraph> <paragraph>Concomitant administration of esomeprazole and a combined inhibitor of CYP2C19 and CYP3A4, such as voriconazole, may result in more than doubling of the esomeprazole exposure. Dose adjustment of esomeprazole is not normally required. However, in patients with Zollinger-Ellison’s Syndrome, who may require higher doses up to 240 mg/day, dose adjustment may be considered.</paragraph> <paragraph>Drugs known to induce CYP2C19 or CYP3A4 or both (such as rifampin) may lead to decreased esomeprazole serum levels. Omeprazole, of which esomeprazole is an enantiomer, has been reported to interact with St. John’s Wort, an inducer of CYP3A4. In a cross-over study in 12 healthy male subjects, St. John’s Wort (300 mg three times daily for 14 days) significantly decreased the systemic exposure of omeprazole in CYP2C19 poor metabolisers (C_max and AUC decreased by 37.5% and 37.9%, respectively) and extensive metabolisers (C_max and AUC decreased by 49.6 % and 43.9%, respectively). Avoid concomitant use of St. John’s Wort or rifampin with NEXIUM.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_77910ec6-4020-413f-8faa-ea47448c5a7a"> <id root="7dd53be5-ffea-4ac5-8062-b1fb56df72e9"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.4 Interactions with Investigations of Neuroendocrine Tumors</title> <text> <paragraph>Drug-induced decrease in gastric acidity results in enterochromaffin-like cell hyperplasia and increased Chromogranin A levels which may interfere with investigations for neuroendocrine tumors <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#ID_5b766617-0025-47db-9f43-e99bb2b62604">Warnings and Precautions (5.10)</linkHtml> </content> <content styleCode="italics"> and <linkHtml href="#williamsonbk1310048423179">Clinical Pharmacology (12.2)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_be504ea1-eb95-4c98-bb94-4ed076f9078e"> <id root="ba11fbcd-37cf-48be-bb20-c5d0bdb79492"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.5 Tacrolimus</title> <text> <paragraph>Concomitant administration of esomeprazole and tacrolimus may increase the serum levels of tacrolimus.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> <component> <section ID="ID_76b3d0a2-da45-46d4-8934-0556e6d6e14a"> <id root="ea7de532-1f40-4e5c-8f49-712bd269a1bc"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.6 Combination Therapy with Clarithromycin</title> <text> <paragraph>Co-administration of esomeprazole, clarithromycin, and amoxicillin has resulted in increases in the plasma levels of esomeprazole and 14-hydroxyclarithromycin <content styleCode="italics">[see <linkHtml href="#williamsonbk1158777874678">Clinical Pharmacology (12.4)</linkHtml>]</content>.</paragraph> <paragraph>Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions due to drug interactions <content styleCode="italics">[see Warnings and Precautions in prescribing information for clarithromycin]</content>. Because of these drug interactions, clarithromycin is contraindicated for co-administration with certain drugs <content styleCode="italics">[see Contraindications in prescribing information for clarithromycin]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="williamsonbk1327936521605"> <id root="b51f8535-e54e-4587-aa66-96cbd0b67c06"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>7.7 Methotrexate</title> <text> <paragraph>Case reports, published population pharmacokinetic studies, and retrospective analyses suggest that concomitant administration of PPIs and methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite hydroxymethotrexate. However, no formal drug interaction studies of methotrexate with PPIs have been conducted <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#williamsonbk1327936497308">Warnings and Precautions (5.11)</linkHtml> </content> <content styleCode="italics">]</content>.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_65e138da-3c44-4da1-9ce0-95dff78ce218"> <id root="c38b530f-3001-4beb-ba85-2345810c1e03"/> <code code="43684-0" codeSystem="2.16.840.1.113883.6.1" displayName="USE IN SPECIFIC POPULATIONS SECTION"/> <title>8 USE IN SPECIFIC POPULATIONS</title> <effectiveTime value="20180607"/> <component> <section ID="ID_fed44a3f-e710-470b-bcf1-e9a97154dbaf"> <id root="c928b9cf-1589-4167-b642-993934cdbbc3"/> <code code="42228-7" codeSystem="2.16.840.1.113883.6.1" displayName="PREGNANCY SECTION"/> <title>8.1 Pregnancy</title> <text> <paragraph> <content styleCode="bold">Risk Summary</content> </paragraph> <paragraph>There are no adequate and well-controlled studies with NEXIUM in pregnant women. Esomeprazole is the S-isomer of omeprazole. Available epidemiologic data fail to demonstrate an increased risk of major congenital malformations or other adverse pregnancy outcomes with first trimester omeprazole use. Reproduction studies in rats and rabbits resulted in dose-dependent embryo-lethality at omeprazole doses that were approximately 3.4 to 34 times an oral human dose of 40 mg (based on a body surface area for a 60 kg person). </paragraph> <paragraph>Teratogenicity was not observed in animal reproduction studies with administration of oral esomeprazole magnesium in rats and rabbits with doses about 68 times and 42 times, respectively, an oral human dose of 40 mg (based on a body surface area basis for a 60 kg person). Changes in bone morphology were observed in offspring of rats dosed through most of pregnancy and lactation at doses equal to or greater than approximately 34 times an oral human dose of 40 mg. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age <content styleCode="italics">[see Data]</content>. </paragraph> <paragraph>The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.</paragraph> <paragraph> <content styleCode="bold">Data</content> </paragraph> <paragraph> <content styleCode="italics">Human Data</content> </paragraph> <paragraph>Esomeprazole is the S-isomer of omeprazole. Four epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used omeprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H₂-receptor antagonists or other controls. </paragraph> <paragraph>A population-based retrospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, from 1995 to 1999, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used omeprazole during pregnancy. The number of infants exposed in utero to omeprazole that had any malformation, low birth weight, low Apgar score, or hospitalization was similar to the number observed in this population. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in this population. </paragraph> <paragraph>A population-based retrospective cohort study covering all live births in Denmark from 1996 to 2009, reported on 1,800 live births whose mothers used omeprazole during the first trimester of pregnancy and 837,317 live births whose mothers did not use any proton pump inhibitor. The overall rate of birth defects in infants born to mothers with first trimester exposure to omeprazole was 2.9% and 2.6% in infants born to mothers not exposed to any proton pump inhibitor during the first trimester.</paragraph> <paragraph>A retrospective cohort study reported on 689 pregnant women exposed to either H₂-blockers or omeprazole in the first trimester (134 exposed to omeprazole) and 1,572 pregnant women unexposed to either during the first trimester. The overall malformation rate in offspring born to mothers with first trimester exposure to omeprazole, an H₂-blocker, or were unexposed was 3.6%, 5.5%, and 4.1% respectively. </paragraph> <paragraph>A small prospective observational cohort study followed 113 women exposed to omeprazole during pregnancy (89% with first trimester exposures). The reported rate of major congenital malformations was 4% in the omeprazole group, 2% in controls exposed to non-teratogens, and 2.8% in disease paired controls. Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight were similar among the groups. </paragraph> <paragraph>Several studies have reported no apparent adverse short-term effects on the infant when single dose oral or intravenous omeprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia.</paragraph> <paragraph> <content styleCode="italics">Animal Data</content> </paragraph> <paragraph> <content styleCode="underline">Omeprazole</content> </paragraph> <paragraph>Reproductive studies conducted with omeprazole in rats at oral doses up to 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at doses up to 69.1 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) during organogenesis did not disclose any evidence for a teratogenic potential of omeprazole. In rabbits, omeprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with omeprazole at 13.8 to 138.0 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis), administered prior to mating through the lactation period.</paragraph> <paragraph> <content styleCode="underline">Esomeprazole</content> </paragraph> <paragraph>No effects on embryo-fetal development were observed in reproduction studies with esomeprazole magnesium in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) or in rabbits at oral doses up to 86 mg/kg/day (about 41 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis. </paragraph> <paragraph>A pre- and postnatal developmental toxicity study in rats with additional endpoints to evaluate bone development was performed with esomeprazole magnesium at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). Neonatal/early postnatal (birth to weaning) survival was decreased at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Body weight and body weight gain were reduced and neurobehavioral or general developmental delays in the immediate post-weaning timeframe were evident at doses equal to or greater than 69 mg/kg/day (about 17 times an oral human dose of 40 mg on a body surface area basis). In addition, decreased femur length, width and thickness of cortical bone, decreased thickness of the tibial growth plate and minimal to mild bone marrow hypocellularity were noted at doses equal to or greater than 14 mg/kg/day (about 3.4 times an oral human dose of 40 mg on a body surface area basis). Physeal dysplasia in the femur was observed in offspring of rats treated with oral doses of esomeprazole magnesium at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). </paragraph> <paragraph>Effects on maternal bone were observed in pregnant and lactating rats in a pre- and postnatal toxicity study when esomeprazole magnesium was administered at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). When rats were dosed from gestational day 7 through weaning on postnatal day 21, a statistically significant decrease in maternal femur weight of up to 14% (as compared to placebo treatment) was observed at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).</paragraph> <paragraph>A pre- and postnatal development study in rats with esomeprazole strontium (using equimolar doses compared to esomeprazole magnesium study) produced similar results in dams and pups as described above.</paragraph> <paragraph>A follow up developmental toxicity study in rats with further time points to evaluate pup bone development from postnatal day 2 to adulthood was performed with esomeprazole magnesium at oral doses of 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) where esomeprazole administration was from either gestational day 7 or gestational day 16 until parturition. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_b19b5222-79d0-4c15-ad6e-4ef33db3b075"> <id root="9fe6d5aa-ed04-41c9-9ec8-102d084fa746"/> <code code="77290-5" codeSystem="2.16.840.1.113883.6.1" displayName="LACTATION SECTION"/> <title>8.2 Lactation </title> <text> <paragraph> <content styleCode="bold">Risk Summary </content> </paragraph> <paragraph>Esomeprazole is the S-isomer of omeprazole and limited data suggest that omeprazole may be present in human milk. There are no clinical data on the effects of esomeprazole on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for NEXIUM and any potential adverse effects on the breastfed infant from NEXIUM or from the underlying maternal condition.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_8f087c07-d7fe-4224-a1cc-fb2272cacf4e"> <id root="29712ee3-33b8-494b-92cb-392b30fc2ce9"/> <code code="34081-0" codeSystem="2.16.840.1.113883.6.1" displayName="PEDIATRIC USE SECTION"/> <title>8.4 Pediatric Use </title> <text> <paragraph>The safety and effectiveness of NEXIUM have been established in pediatric patients 1 to 17 years of age for short-term treatment (up to eight weeks) of GERD. The safety and effectiveness of NEXIUM have been established in pediatric patients 1 month to less than 1 year for short-term treatment (up to 6 weeks) of erosive esophagitis due to acid-mediated GERD. However, the safety and effectiveness of NEXIUM have not been established in patients less than 1 month of age.</paragraph> <paragraph> <content styleCode="italics">1 to 17 years of age </content> </paragraph> <paragraph>Use of NEXIUM in pediatric and adolescent patients 1 to 17 years of age for short-term treatment (up to eight weeks) of GERD is supported by extrapolation of results from adequate and well-controlled studies for adults and safety and pharmacokinetic studies performed in pediatric and adolescent patients <content styleCode="italics">[see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml>, <linkHtml href="#_Ref">Adverse Reactions (6.1)</linkHtml>, <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml>, and <linkHtml href="#williamsonbk1185378883110">Clinical Studies (14.3)</linkHtml>]</content>. The safety and effectiveness of NEXIUM for other pediatric uses have not been established. </paragraph> <paragraph> <content styleCode="italics">Erosive esophagitis due to acid-mediated GERD in infants 1 month to less than one year of age</content> </paragraph> <paragraph>Use of NEXIUM in pediatric patients 1 month to less than 1 year of age for treatment (up to 6 weeks) of erosive esophagitis due to acid-mediated GERD is supported by extrapolation of results from adequate and well-controlled studies for adults and safety, pharmacokinetic, and pharmacodynamic studies performed in pediatric patients <content styleCode="italics">[see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml>, <linkHtml href="#_Ref">Adverse Reactions (6.1)</linkHtml>, <linkHtml href="#williamsonbk1185372821742">Clinical Pharmacology (12.3)</linkHtml>, and <linkHtml href="#williamsonbk1185378883110">Clinical Studies (14.3)</linkHtml>]</content>.</paragraph> <paragraph> <content styleCode="italics">Symptomatic GERD in infants 1 month to less than one year of age</content> </paragraph> <paragraph>There was no statistically significant difference between NEXIUM and placebo in the rate of discontinuation due to symptom worsening in a multicenter, randomized, double-blind, controlled, treatment-withdrawal study of 98 patients ages 1 to 11 months, inclusive. Patients were enrolled if they had either a clinical diagnosis of suspected GERD, symptomatic GERD, or endoscopically proven GERD. Twenty of 98 enrolled patients underwent endoscopy, and 6 patients were found to have erosive esophagitis on endoscopy at baseline. All patients received NEXIUM Delayed-Release Oral Suspension once daily during a two-week, open-label phase of the study. </paragraph> <paragraph>There were 80 patients who attained a pre-specified level of symptom improvement and who entered the double-blind phase, in which they were randomized in equal proportions to receive NEXIUM or placebo for the next four weeks. Efficacy was assessed by observing the time from randomization to study discontinuation due to symptom worsening during the four-week, treatment-withdrawal phase. </paragraph> <paragraph>The following pharmacokinetic and pharmacodynamic information was obtained in pediatric patients with GERD aged birth to less than one year of age. In infants (1 to 11 months old, inclusive) given NEXIUM 1 mg/kg once daily, the percent time with intragastric pH &gt; 4 increased from 29% at baseline to 69% on Day 7, which is similar to the pharmacodynamic effect in adults <content styleCode="italics">[see <linkHtml href="#williamsonbk1310048423179">Clinical Pharmacology (12.2)</linkHtml>]</content>. Apparent clearance (CL/F) increases with age in pediatric patients from birth to 2 years of age. </paragraph> <paragraph> <content styleCode="italics">Neonates 0 to 1 month of age </content> </paragraph> <paragraph>Following administration of oral NEXIUM in neonates the geometric mean (range) for the apparent clearance (CL/F) was 0.55 L/h/kg (0.25-1.6 L/h/kg). </paragraph> <paragraph>The safety and effectiveness of NEXIUM in neonates have not been established.</paragraph> <paragraph> <content styleCode="italics">Juvenile Animal Data</content> </paragraph> <paragraph>In a juvenile rat toxicity study, esomeprazole was administered with both magnesium and strontium salts at oral doses about 34 to 68 times a daily human dose of 40 mg based on body surface area. Increases in death were seen at the high dose, and at all doses of esomeprazole, there were decreases in body weight, body weight gain, femur weight and femur length, and decreases in overall growth <content styleCode="italics">[see <linkHtml href="#rowellsl1309364337994">Nonclinical Toxicology (13.2)</linkHtml>]</content>.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="ID_561b6505-6865-4a1b-9e71-ae852272957b"> <id root="0fee2149-f259-4d63-9f3d-815df15e2cd3"/> <code code="34082-8" codeSystem="2.16.840.1.113883.6.1" displayName="GERIATRIC USE SECTION"/> <title>8.5 Geriatric Use </title> <text> <paragraph>Of the total number of patients who received NEXIUM in clinical trials, 1459 were 65 to 74 years of age and 354 patients were ≥ 75 years of age.</paragraph> <paragraph>No overall differences in safety and efficacy were observed between the elderly and younger individuals, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_1bb4bf7d-8d75-444d-8a00-4c0186a8bca0"> <id root="220ad211-273b-4933-ba41-f3f8a15ac25a"/> <code code="34088-5" codeSystem="2.16.840.1.113883.6.1" displayName="OVERDOSAGE SECTION"/> <title>10 OVERDOSAGE</title> <text> <paragraph>A single oral dose of esomeprazole at 510 mg/kg (about 124 times the human dose on a body surface area basis), was lethal to rats. The major signs of acute toxicity were reduced motor activity, changes in respiratory frequency, tremor, ataxia, and intermittent clonic convulsions.</paragraph> <paragraph>The symptoms described in connection with deliberate NEXIUM overdose (limited experience of doses in excess of 240 mg/day) are transient. Single doses of 80 mg of esomeprazole were uneventful. Reports of overdosage with omeprazole in humans may also be relevant. Doses ranged up to 2,400 mg (120 times the usual recommended clinical dose). Manifestations were variable, but included confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen in normal clinical experience (see omeprazole package insert - <content styleCode="italics">Adverse Reactions</content>). No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive.</paragraph> <paragraph>As with the management of any overdose, the possibility of multiple drug ingestion should be considered. For current information on treatment of any drug overdose contact a Poison Control Center at 1–800–222–1222.</paragraph> </text> <effectiveTime value="20160125"/> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1244206518104"> <id root="50066050-2c12-4535-83cc-f3c2a38b6056"/> <code code="34089-3" codeSystem="2.16.840.1.113883.6.1" displayName="DESCRIPTION SECTION"/> <title>11 DESCRIPTION</title> <text> <paragraph>The active ingredient in the proton pump inhibitor NEXIUM^® (esomeprazole magnesium) Delayed-Release Capsules for oral administration and NEXIUM (esomeprazole magnesium) For Delayed-Release Oral Suspension is bis(5-methoxy-2-[(S)-[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1<content styleCode="italics">H</content>-benzimidazole-1-yl) magnesium trihydrate. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is (C₁₇H₁₈N₃O₃S)₂Mg x 3 H₂O with molecular weight of 767.2 as a trihydrate and 713.1 on an anhydrous basis. The structural formula is:</paragraph> <renderMultiMedia ID="id2361" referencedObject="E326B93E-17C5-4BBF-A085-4F9E1125C25E"> <caption>Figure 1</caption> </renderMultiMedia> <paragraph>The magnesium salt is a white to slightly colored crystalline powder. It contains 3 moles of water of solvation and is slightly soluble in water. The stability of esomeprazole magnesium is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C.</paragraph> <paragraph>NEXIUM is supplied in delayed-release capsules and in packets for a delayed-release oral suspension. Each delayed-release capsule contains 20 mg, or 40 mg of esomeprazole (present as 22.3 mg, or 44.5 mg esomeprazole magnesium trihydrate) in the form of enteric-coated granules with the following inactive ingredients: glyceryl monostearate 40-55, hydroxypropyl cellulose, hypromellose, magnesium stearate, methacrylic acid copolymer type C, polysorbate 80, sugar spheres, talc, and triethyl citrate. The capsule shells have the following inactive ingredients: gelatin, FD&amp;C Blue #1, FD&amp;C Red #40, D&amp;C Red #28, titanium dioxide, shellac, ethyl alcohol, isopropyl alcohol, n-butyl alcohol, propylene glycol, sodium hydroxide, polyvinyl pyrrolidone, and D&amp;C Yellow #10.</paragraph> <paragraph>Each packet of NEXIUM For Delayed-Release Oral Suspension contains 2.5 mg, 5 mg, 10 mg, 20 mg, or 40 mg of esomeprazole, in the form of the same enteric-coated granules used in NEXIUM Delayed-Release Capsules, and also inactive granules. The inactive granules are composed of the following ingredients: dextrose, xanthan gum, crospovidone, citric acid, iron oxide, and hydroxypropyl cellulose. The esomeprazole granules and inactive granules are constituted with water to form a suspension and are given by oral, nasogastric, or gastric administration.</paragraph> </text> <effectiveTime value="20161220"/> <component> <observationMedia ID="E326B93E-17C5-4BBF-A085-4F9E1125C25E"> <text>Structural Formula</text> <value mediaType="image/jpeg"> <reference value="image-01.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1158843286000"> <id root="a95132e9-291a-484a-a452-1b36c213c292"/> <code code="34090-1" codeSystem="2.16.840.1.113883.6.1" displayName="CLINICAL PHARMACOLOGY SECTION"/> <title>12 CLINICAL PHARMACOLOGY</title> <effectiveTime value="20180607"/> <component> <section ID="ID_189fbee8-3756-46e0-b204-a5f4648c5fba"> <id root="17d86352-1949-435b-aaaa-abdc190b8e91"/> <code code="43679-0" codeSystem="2.16.840.1.113883.6.1" displayName="MECHANISM OF ACTION SECTION"/> <title>12.1 Mechanism of Action</title> <text> <paragraph>Esomeprazole is a proton pump inhibitor that suppresses gastric acid secretion by specific inhibition of the H⁺/K⁺-ATPase in the gastric parietal cell. The S- and R-isomers of omeprazole are protonated and converted in the acidic compartment of the parietal cell forming the active inhibitor, the achiral sulphenamide. By acting specifically on the proton pump, esomeprazole blocks the final step in acid production, thus reducing gastric acidity. This effect is dose-related up to a daily dose of 20 to 40 mg and leads to inhibition of gastric acid secretion.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> <component> <section ID="williamsonbk1310048423179"> <id root="fcdf8c71-4d26-4695-9d2f-ed0bd1bd683b"/> <code code="43681-6" codeSystem="2.16.840.1.113883.6.1" displayName="PHARMACODYNAMICS SECTION"/> <title>12.2 Pharmacodynamics</title> <text> <paragraph> <content styleCode="italics">Antisecretory Activity</content> </paragraph> <paragraph>The effect of NEXIUM on intragastric pH was determined in patients with symptomatic gastroesophageal reflux disease in two separate studies. In the first study of 36 patients, NEXIUM 40 mg and 20 mg capsules were administered over 5 days. The results are shown in the Table 3:</paragraph> <table width="100%"> <caption>Table 3: Effect on Intragastric pH on Day 5 (N=36)</caption> <col width="58%"/> <col width="21%"/> <col width="21%"/> <tbody> <tr> <td styleCode="Rrule Botrule Toprule " valign="top"> <paragraph>Parameter</paragraph> </td> <td styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph>NEXIUM</paragraph> <paragraph>40 mg</paragraph> </td> <td styleCode="Botrule Lrule Toprule " valign="top"> <paragraph>NEXIUM</paragraph> <paragraph>20 mg </paragraph> </td> </tr> <tr> <td styleCode="Rrule Botrule " valign="top"> <paragraph>% Time Gastric pH &gt;4<footnote ID="_RefFN1158778256-1">Gastric pH was measured over a 24-hour period</footnote>(Hours)</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>70%<footnote ID="_RefFN1158778311-1">p&lt; 0.01 NEXIUM 40 mg vs. NEXIUM 20 mg</footnote> </paragraph> <paragraph>(16.8 h)</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>53%</paragraph> <paragraph>(12.7 h)</paragraph> </td> </tr> <tr> <td styleCode="Rrule Botrule " valign="top"> <paragraph> Coefficient of variation</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>26%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>37%</paragraph> </td> </tr> <tr> <td styleCode="Rrule Botrule " valign="top"> <paragraph>Median 24 Hour pH</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>4.9<footnoteRef IDREF="_RefFN1158778311-1"/> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>4.1</paragraph> </td> </tr> <tr> <td styleCode="Rrule Botrule " valign="top"> <paragraph>Coefficient of variation</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>16%</paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>27%</paragraph> </td> </tr> </tbody> </table> <paragraph>In a second study, the effect on intragastric pH of NEXIUM 40 mg administered once daily over a five day period was similar to the first study, (% time with pH &gt; 4 was 68% or 16.3 hours).</paragraph> <paragraph> <content styleCode="italics">Serum Gastrin Effects </content> </paragraph> <paragraph>The effect of NEXIUM on serum gastrin concentrations was evaluated in approximately 2,700 patients in clinical trials up to 8 weeks and in over 1,300 patients for up to 6 to 12 months. The mean fasting gastrin level increased in a dose-related manner. This increase reached a plateau within two to three months of therapy and returned to baseline levels within four weeks after discontinuation of therapy.</paragraph> <paragraph>Increased gastrin causes enterochromaffin-like cell hyperplasia and increased serum Chromogranin A (CgA) levels. The increased CgA levels may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high.</paragraph> <paragraph> <content styleCode="italics">Enterochromaffin-like (ECL) Cell Effects </content> </paragraph> <paragraph>In 24-month carcinogenicity studies of omeprazole in rats, a dose-related significant occurrence of gastric ECL cell carcinoid tumors and ECL cell hyperplasia was observed in both male and female animals <content styleCode="italics">[see <linkHtml href="#williamsonbk1158778438991">Nonclinical Toxicology (13.1)</linkHtml>]</content>. Carcinoid tumors have also been observed in rats subjected to fundectomy or long-term treatment with other proton pump inhibitors or high doses of H₂-receptor antagonists.</paragraph> <paragraph>Human gastric biopsy specimens have been obtained from more than 3,000 patients (both children and adults) treated with omeprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients. </paragraph> <paragraph>In over 1,000 patients treated with NEXIUM (10, 20 or 40 mg/day) up to 6 to 12 months, the prevalence of ECL cell hyperplasia increased with time and dose. No patient developed ECL cell carcinoids, dysplasia, or neoplasia in the gastric mucosa.</paragraph> <paragraph> <content styleCode="italics">Endocrine Effects</content> </paragraph> <paragraph>NEXIUM had no effect on thyroid function when given in oral doses of 20 or 40 mg for 4 weeks. Other effects of NEXIUM on the endocrine system were assessed using omeprazole studies. Omeprazole given in oral doses of 30 or 40 mg for 2 to 4 weeks had no effect on carbohydrate metabolism, circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin, or secretin.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> <component> <section ID="williamsonbk1185372821742"> <id root="ba824724-b5a3-42d2-896d-ee22302a0341"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>12.3 Pharmacokinetics</title> <text> <paragraph> <content styleCode="italics">Absorption</content> </paragraph> <paragraph>NEXIUM Delayed-Release Capsules and NEXIUM For Delayed-Release Oral Suspension contain a bioequivalent enteric-coated granule formulation of esomeprazole magnesium. Bioequivalency is based on a single dose (40 mg) study in 94 healthy male and female volunteers under fasting condition. After oral administration, peak plasma levels (C_max) occur at approximately 1.5 hours (T_max). The C_maxincreases proportionally when the dose is increased, and there is a three-fold increase in the area under the plasma concentration-time curve (AUC) from 20 to 40 mg. At repeated once-daily dosing with 40 mg, the systemic bioavailability is approximately 90% compared to 64% after a single dose of 40 mg. The mean exposure (AUC) to esomeprazole increases from 4.32 µmol*hr/L on Day 1 to 11.2 µmol*hr/L on Day 5 after 40 mg once daily dosing.</paragraph> <paragraph>The AUC after administration of a single 40 mg dose of NEXIUM is decreased by 43% to 53% after food intake compared to fasting conditions. NEXIUM should be taken at least one hour before meals.</paragraph> <paragraph>The pharmacokinetic profile of NEXIUM was determined in 36 patients with symptomatic gastroesophageal reflux disease following repeated once daily administration of 20 mg and 40 mg capsules of NEXIUM over a period of five days. The results are shown in the Table 4:</paragraph> <table width="100%"> <caption>Table 4: Pharmacokinetic Parameters of NEXIUM on Day 5 Following Oral Dosing for 5 Days</caption> <col width="43%"/> <col width="30%"/> <col width="27%"/> <tbody> <tr> <td styleCode="Botrule Toprule " valign="top"> <paragraph>Parameter <footnote ID="_Ref330983931">Values represent the geometric mean, except the T_max, which is the arithmetic mean; CV = Coefficient of variation</footnote> (CV)</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph>NEXIUM </paragraph> <paragraph>40 mg </paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph>NEXIUM </paragraph> <paragraph>20 mg </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>AUC (μmol·h/L)</paragraph> </td> <td valign="top"> <paragraph>12.6 (42%)</paragraph> </td> <td valign="top"> <paragraph>4.2 (59%)</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>C_max (μmol/L)</paragraph> </td> <td valign="top"> <paragraph>4.7 (37%)</paragraph> </td> <td valign="top"> <paragraph>2.1 (45%)</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>T_max (h)</paragraph> </td> <td valign="top"> <paragraph>1.6</paragraph> </td> <td valign="top"> <paragraph>1.6</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"> <paragraph>t_1/2 (h)</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>1.5</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>1.2</paragraph> </td> </tr> </tbody> </table> <paragraph> <content styleCode="italics">Distribution</content> </paragraph> <paragraph>Esomeprazole is 97% bound to plasma proteins. Plasma protein binding is constant over the concentration range of 2 to 20 μmol/L. The apparent volume of distribution at steady state in healthy volunteers is approximately 16 L.</paragraph> <paragraph> <content styleCode="italics">Elimination</content> </paragraph> <paragraph> <content styleCode="underline">Metabolism</content> </paragraph> <paragraph>Esomeprazole is extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole’s metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite. CYP2C19 isoenzyme exhibits polymorphism in the metabolism of esomeprazole, since some 3% of Caucasians and 15 to 20% of Asians lack CYP2C19 and are termed Poor Metabolizers. At steady state, the ratio of AUC in Poor Metabolizers to AUC in the rest of the population (Extensive Metabolizers) is approximately 2.</paragraph> <paragraph>Following administration of equimolar doses, the S- and R-isomers are metabolized differently by the liver, resulting in higher plasma levels of the S- than of the R-isomer.</paragraph> <paragraph> <content styleCode="underline">Excretion</content> </paragraph> <paragraph>The plasma elimination half-life of esomeprazole is approximately 1 to 1.5 hours. Less than 1% of parent drug is excreted in the urine. Approximately 80% of an oral dose of esomeprazole is excreted as inactive metabolites in the urine, and the remainder is found as inactive metabolites in the feces. </paragraph> <paragraph> <content styleCode="italics">Combination Therapy with Antimicrobials</content> </paragraph> <paragraph>Esomeprazole magnesium 40 mg once daily was given in combination with clarithromycin 500 mg twice daily and amoxicillin 1000 mg twice daily for 7 days to 17 healthy male and female subjects. The mean steady state AUC and C_max of esomeprazole increased by 70% and 18%, respectively during triple combination therapy compared to treatment with esomeprazole alone. The observed increase in esomeprazole exposure during co-administration with clarithromycin and amoxicillin is not expected to produce significant safety concerns.</paragraph> <paragraph>The pharmacokinetic parameters for clarithromycin and amoxicillin were similar during triple combination therapy and administration of each drug alone. However, the mean AUC and C_max for 14-hydroxyclarithromycin increased by 19% and 22%, respectively, during triple combination therapy compared to treatment with clarithromycin alone. This increase in exposure to 14-hydroxyclarithromycin is not considered to be clinically significant.</paragraph> <paragraph> <content styleCode="bold">Concomitant Use with Clopidogrel</content> </paragraph> <paragraph>Results from a crossover study in healthy subjects have shown a pharmacokinetic interaction between clopidogrel (300 mg loading dose/75 mg daily maintenance dose) and esomeprazole (40 mg p.o. once daily) when co-administered for 30 days. Exposure to the active metabolite of clopidogrel was reduced by 35% to 40% over this time period. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation was related to the change in the exposure to clopidogrel active metabolite.</paragraph> <paragraph> <content styleCode="bold">Concomitant Use with Mycophenolate Mofetil</content> </paragraph> <paragraph>Administration of omeprazole 20 mg twice daily for 4 days and a single 1000 mg dose of MMF approximately one hour after the last dose of omeprazole to 12 healthy subjects in a cross-over study resulted in a 52% reduction in the C_max and 23% reduction in the AUC of MPA.</paragraph> <paragraph> <content styleCode="bold">Specific Populations </content> </paragraph> <paragraph> <content styleCode="italics">Age: Geriatric Population</content> </paragraph> <paragraph>The AUC and C_max values were slightly higher (25% and 18%, respectively) in the elderly as compared to younger subjects at steady state. Dosage adjustment based on age is not necessary.</paragraph> <paragraph> <content styleCode="italics">Age: Pediatric Population</content> </paragraph> <paragraph> <content styleCode="italics">1 to 11 Month of Age</content> </paragraph> <paragraph>The pharmacokinetic parameters following repeated dose administration of 1.0 mg/kg esomeprazole in 1 to 11 month old infants are summarized in Table 5.</paragraph> <table width="100%"> <caption>Table 5: Summary of PK Parameters in 1 Month to &lt; 1 Year Olds with GERD Following 7/8 Days of Once-Daily Oral Esomeprazole Treatment</caption> <col width="55%"/> <col width="45%"/> <tbody> <tr> <td styleCode="Rrule Botrule Lrule Toprule " valign="top"/> <td styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph>1 month to &lt; 1 year</paragraph> </td> </tr> <tr> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>Parameter</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>1.0 mg/kg</paragraph> </td> </tr> <tr> <td styleCode="Rrule Lrule Botrule " valign="top"/> <td styleCode="Rrule Lrule Botrule " valign="top"/> </tr> <tr> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>AUC (μmol·h/L) (n=7)<footnote ID="_RefFN1324405348-1">Geometric mean</footnote> </paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>3.51</paragraph> </td> </tr> <tr> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>C_ss,,max (μmol/L) (n=15)<footnoteRef IDREF="_RefFN1324405348-1"/> </paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>0.87</paragraph> </td> </tr> <tr> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>t_½ (hours) (n=8)<footnoteRef IDREF="_RefFN1324405348-1"/> </paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>0.93</paragraph> </td> </tr> <tr> <td styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>t_max (hours) (n=15)<footnote ID="_RefFN1324405519-1">Median</footnote> </paragraph> </td> <td styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>3.0</paragraph> </td> </tr> </tbody> </table> <paragraph>Subsequent pharmacokinetic simulation analyses showed that a dosage regimen of 2.5 mg once-daily for pediatric patients with body weight 3 to 5 kg, 5.0 mg once-daily for &gt;5 to 7.5 kg and 10 mg once-daily for &gt;7.5 to 12 kg would achieve comparable steady-state plasma exposures (AUC) to that observed after 10 mg in 1 to 11 year olds, and 20 mg in 12 to 18 year-olds as well as adults.</paragraph> <paragraph> <content styleCode="italics">1 to 11 Years of Age</content> </paragraph> <paragraph>The pharmacokinetics of esomeprazole were studied in pediatric patients with GERD aged 1 to 11 years. Following once daily dosing for 5 days, the total exposure (AUC) for the 10 mg dose in patients aged 6 to 11 years was similar to that seen with the 20 mg dose in adults and adolescents aged 12 to 17 years. The total exposure for the 10 mg dose in patients aged 1 to 5 years was approximately 30% higher than the 10 mg dose in patients aged 6 to 11 years. The total exposure for the 20 mg dose in patients aged 6 to 11 years was higher than that observed with the 20 mg dose in 12 to 17 year-olds and adults, but lower than that observed with the 40 mg dose in 12 to 17 year-olds and adults. See Table 6.</paragraph> <table width="100%"> <caption>Table 6: Summary of PK Parameters in 1 to 11 Year Olds with GERD following 5 Days of Once-Daily Oral Esomeprazole Treatment</caption> <col width="28%"/> <col width="28%"/> <col width="22%"/> <col width="22%"/> <tbody> <tr> <td styleCode="Botrule Lrule Toprule " valign="top"/> <td align="center" styleCode="Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold">1 to 5 Year Olds</content> </paragraph> </td> <td align="center" colspan="2" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold">6 to 11 Year Olds</content> </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">Parameter</content> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">10 mg (N=8)</content> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">10 mg (N=7)</content> </paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph> <content styleCode="bold">20 mg (N=6)</content> </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>AUC (μmol·h/L)<footnote ID="_RefFN1158779590-1">Geometric mean</footnote> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>4.83</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>3.70</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>6.28</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>C_max (μmol/L)<footnoteRef IDREF="_RefFN1158779590-1"/> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>2.98</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1.77</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>3.73</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>t_max (h)<footnote ID="_RefFN1158779716-1">Arithmetic mean</footnote> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1.44</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1.79</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>1.75</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>t_½λz (h)<footnoteRef IDREF="_RefFN1158779590-1"/> </paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0.74</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0.88</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>0.73</paragraph> </td> </tr> <tr> <td styleCode="Botrule Lrule " valign="top"> <paragraph>Cl/F (L/h)<footnoteRef IDREF="_RefFN1158779590-1"/> </paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>5.99</paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>7.84</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>9.22</paragraph> </td> </tr> </tbody> </table> <paragraph> <content styleCode="italics">12 to 17 Years of Age</content> </paragraph> <paragraph>The pharmacokinetics of NEXIUM were studied in 28 adolescent patients with GERD aged 12 to 17 years inclusive, in a single center study. Patients were randomized to receive NEXIUM 20 mg or 40 mg once daily for 8 days. Mean C_max and AUC values of esomeprazole were not affected by body weight or age; and more than dose-proportional increases in mean C_max and AUC values were observed between the two dose groups in the study. Overall, NEXIUM pharmacokinetics in adolescent patients aged 12 to 17 years were similar to those observed in adult patients with symptomatic GERD. See Table 7.</paragraph> <table width="100%"> <caption>Table 7: Comparison of PK Parameters in 12 to 17 Year Olds with GERD and Adults with Symptomatic GERD Following the Repeated Daily Oral Dose Administration of Esomeprazole<footnote ID="_RefFN1158841368-1">Duration of treatment for 12 to 17 year olds and adults were 8 days and 5 days, respectively. Data were obtained from two independent studies.</footnote> </caption> <col width="29%"/> <col width="22%"/> <col width="22%"/> <col width="13%"/> <col width="13%"/> <tbody> <tr> <td styleCode="Toprule " valign="top"/> <td align="center" colspan="2" styleCode="Toprule " valign="top"> <paragraph> <content styleCode="bold">12 to 17 Year Olds (N=28)</content> </paragraph> </td> <td align="center" colspan="2" styleCode="Toprule " valign="top"> <paragraph> <content styleCode="bold">Adults (N=36)</content> </paragraph> </td> </tr> <tr> <td valign="top"/> <td valign="top"> <paragraph> <content styleCode="bold">20 mg </content> </paragraph> </td> <td valign="top"> <paragraph> <content styleCode="bold">40 mg </content> </paragraph> </td> <td valign="top"> <paragraph> <content styleCode="bold">20 mg</content> </paragraph> </td> <td valign="top"> <paragraph> <content styleCode="bold">40 mg</content> </paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>AUC (μmol·h/L)</paragraph> </td> <td valign="top"> <paragraph>3.65</paragraph> </td> <td valign="top"> <paragraph>13.86</paragraph> </td> <td valign="top"> <paragraph>4.2</paragraph> </td> <td valign="top"> <paragraph>12.6</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>C_max (μmol/L)</paragraph> </td> <td valign="top"> <paragraph>1.45</paragraph> </td> <td valign="top"> <paragraph>5.13</paragraph> </td> <td valign="top"> <paragraph>2.1</paragraph> </td> <td valign="top"> <paragraph>4.7</paragraph> </td> </tr> <tr> <td valign="top"> <paragraph>t_max (h)</paragraph> </td> <td valign="top"> <paragraph>2.00</paragraph> </td> <td valign="top"> <paragraph>1.75</paragraph> </td> <td valign="top"> <paragraph>1.6</paragraph> </td> <td valign="top"> <paragraph>1.6</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"> <paragraph>t_½λz (h)</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>0.82</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>1.22</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>1.2</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>1.5</paragraph> </td> </tr> <tr> <td colspan="5" styleCode="Botrule " valign="top"> <paragraph>Data presented are geometric means for AUC, C_maxand t_½λz, and median value for t_max.</paragraph> </td> </tr> </tbody> </table> <paragraph> <content styleCode="italics">Gender</content> </paragraph> <paragraph>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.</paragraph> <paragraph> <content styleCode="italics">Hepatic Insufficiency</content> </paragraph> <paragraph>The steady state pharmacokinetics of esomeprazole obtained after administration of 40 mg once daily to 4 patients each with mild (Child‑Pugh Class A), moderate (Child‑Pugh Class B), and severe (Child‑Pugh Class C) liver insufficiency were compared to those obtained in 36 male and female GERD patients with normal liver function. In patients with mild and moderate hepatic insufficiency, the AUCs were within the range that could be expected in patients with normal liver function. In patients with severe hepatic insufficiency the AUCs were 2 to 3 times higher than in the patients with normal liver function. No dosage adjustment is recommended for patients with mild to moderate hepatic insufficiency (Child‑Pugh Classes A and B). However, in patients with severe hepatic insufficiency (Child‑Pugh Class C) a dose of 20 mg once daily should not be exceeded <content styleCode="italics">[see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml>]</content>.</paragraph> <paragraph> <content styleCode="italics">Renal Insufficiency</content> </paragraph> <paragraph>The pharmacokinetics of NEXIUM in patients with renal impairment are not expected to be altered relative to healthy volunteers as less than 1% of esomeprazole is excreted unchanged in urine. </paragraph> <paragraph> <content styleCode="italics">Other pharmacokinetic observations </content> </paragraph> <paragraph>Co-administration of oral contraceptives, diazepam, phenytoin, or quinidine did not seem to change the pharmacokinetic profile of esomeprazole. </paragraph> <paragraph>Studies evaluating concomitant administration of esomeprazole and either naproxen (non-selective NSAID) or rofecoxib (COX-2 selective NSAID) did not identify any clinically relevant changes in the pharmacokinetic profiles of esomeprazole or these NSAIDs.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="williamsonbk1158777874678"> <id root="dddfbaca-5708-4276-98e9-7fc32847f623"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>12.4 Microbiology</title> <text> <paragraph>NEXIUM, amoxicillin, and clarithromycin triple therapy has been shown to be active against most strains of <content styleCode="italics">Helicobacter pylori (H. pylori) in vitro</content> and in clinical infections <content styleCode="italics">[see <linkHtml href="#_RefID_0031b420-99d1-4e69-a860-1765bbf61">Indications and Usage (1)</linkHtml> and <linkHtml href="#williamsonbk1158778492663">Clinical Studies (14)</linkHtml>]</content>.</paragraph> <paragraph> <content styleCode="italics">Helicobacter pylori</content>: Susceptibility testing of <content styleCode="italics">H. pylori</content> isolates was performed for amoxicillin and clarithromycin using agar dilution methodology, and minimum inhibitory concentrations (MICs) were determined.</paragraph> <paragraph> <content styleCode="italics">Pretreatment Resistance</content>: Clarithromycin pretreatment resistance rate (MIC ≥ 1 mcg/mL) to <content styleCode="italics">H. pylori</content> was 15% (66/445) at baseline in all treatment groups combined. A total of &gt; 99% (394/395) of patients had <content styleCode="italics">H. pylori</content> isolates that were considered to be susceptible (MIC ≤ 0.25 mcg/mL) to amoxicillin at baseline. One patient had a baseline <content styleCode="italics">H. pylori</content> isolate with an amoxicillin MIC = 0.5 mcg/mL. </paragraph> <paragraph> <content styleCode="italics">Clarithromycin Susceptibility Test Results and Clinical/Bacteriologic Outcomes</content>: The baseline <content styleCode="italics">H. pylori </content>clarithromycin susceptibility results and the <content styleCode="italics">H. pylori</content> eradication results at the Day 38 visit are shown in the Table 8:</paragraph> <table ID="_RefID0EL2BI" width="98.2%"> <caption>Table 8: Clarithromycin Susceptibility Test Results and Clinical/Bacteriological Outcomes<footnote ID="_RefFN1158778815-1">Includes only patients with pretreatment and post-treatment clarithromycin susceptibility test results</footnote> for Triple Therapy - (Esomeprazole magnesium 40 mg once daily/amoxicillin 1000 mg twice daily/clarithromycin 500 mg twice daily for 10 days)</caption> <col width="28%"/> <col width="26%"/> <col width="10%"/> <col width="8%"/> <col width="10%"/> <col width="19%"/> <tbody> <tr> <td align="center" styleCode="Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold">Clarithromycin Pretreatment Results</content> </paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold"> <content styleCode="italics">H.  pylori</content> negative</content> </paragraph> <paragraph> <content styleCode="bold">(Eradicated)</content> </paragraph> </td> <td align="center" colspan="4" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph> <content styleCode="bold"> <content styleCode="italics">H. pylori</content> positive</content> </paragraph> <paragraph> <content styleCode="bold">(Not Eradicated)</content> </paragraph> <paragraph> <content styleCode="bold">Post-treatment susceptibility results</content> </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td styleCode="Rrule Lrule Botrule " valign="top"/> <td styleCode="Lrule Botrule " valign="top"> <paragraph>S <footnote ID="_RefFN1158845236-1">Susceptible (S) MIC ≤ 0.25 mcg/mL, Intermediate (I) MIC = 0.5 mcg/mL, Resistant (R) MIC ≥ 1.0 mcg/mL </footnote> </paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>I<footnoteRef IDREF="_RefFN1158845236-1"/> </paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>R <footnoteRef IDREF="_RefFN1158845236-1"/> </paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>No MIC</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Susceptible<footnoteRef IDREF="_RefFN1158845236-1"/> 182</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>162</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>4</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>2</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>14</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Intermediate<footnoteRef IDREF="_RefFN1158845236-1"/> 1</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>1</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>0</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>0</paragraph> </td> </tr> <tr> <td styleCode="Botrule Lrule " valign="top"> <paragraph>Resistant<footnoteRef IDREF="_RefFN1158845236-1"/> 29</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>13</paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>1</paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>0</paragraph> </td> <td align="center" styleCode="Botrule Lrule " valign="top"> <paragraph>13</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>2</paragraph> </td> </tr> </tbody> </table> <paragraph>Patients not eradicated of <content styleCode="italics">H. pylori</content> following NEXIUM/amoxicillin/clarithromycin triple therapy will likely have clarithromycin resistant <content styleCode="italics">H. pylori</content> isolates. Therefore, clarithromycin susceptibility testing should be done, when possible. Patients with clarithromycin resistant <content styleCode="italics">H. pylori</content> should not be re-treated with a clarithromycin-containing regimen. </paragraph> <paragraph> <content styleCode="italics">Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes:</content> </paragraph> <paragraph>In the NEXIUM/amoxicillin/clarithromycin clinical trials, 83% (176/212) of the patients in the NEXIUM/amoxicillin/clarithromycin treatment group who had pretreatment amoxicillin susceptible MICs (≤ 0.25 mcg/mL) were eradicated of <content styleCode="italics">H. pylori</content>, and 17% (36/212) were not eradicated of <content styleCode="italics">H. pylori</content>. Of the 36 patients who were not eradicated of <content styleCode="italics">H. pylori</content> on triple therapy, 16 had no post-treatment susceptibility test results and 20 had post-treatment <content styleCode="italics">H. pylori</content> isolates with amoxicillin susceptible MICs. Fifteen of the patients who were not eradicated of <content styleCode="italics">H. pylori</content> on triple therapy also had post-treatment <content styleCode="italics">H. pylori</content> isolates with clarithromycin resistant MICs. There were no patients with <content styleCode="italics">H. pylori</content> isolates who developed treatment emergent resistance to amoxicillin.</paragraph> <paragraph> <content styleCode="italics">Susceptibility Test for Helicobacter pylori: </content>For susceptibility testing information about <content styleCode="italics">Helicobacter pylori</content>, see Microbiology section in prescribing information for clarithromycin and amoxicillin.</paragraph> <paragraph> <content styleCode="italics">Effects on Gastrointestinal Microbial Ecology:</content> Decreased gastric acidity due to any means, including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as <content styleCode="italics">Salmonella</content> and <content styleCode="italics">Campylobacter</content> and possibly <content styleCode="italics">Clostridium difficile</content> in hospitalized patients.</paragraph> </text> <effectiveTime value="20180607"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_3706fd83-dd97-4ae8-8a2c-9296ba628eb5"> <id root="eb39b468-0ecd-459f-9ce6-90583a3a988f"/> <code code="43680-8" codeSystem="2.16.840.1.113883.6.1" displayName="NONCLINICAL TOXICOLOGY SECTION"/> <title>13 NONCLINICAL TOXICOLOGY</title> <effectiveTime value="20161220"/> <component> <section ID="williamsonbk1158778438991"> <id root="e849637b-9c78-4f9f-bf7a-d614411c83d9"/> <code code="34083-6" codeSystem="2.16.840.1.113883.6.1" displayName="CARCINOGENESIS &amp; MUTAGENESIS &amp; IMPAIRMENT OF FERTILITY SECTION"/> <title>13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility</title> <text> <paragraph>The carcinogenic potential of NEXIUM was assessed using studies of omeprazole, of which esomeprazole is an enantiomer. In two 24-month oral carcinogenicity studies in rats, omeprazole at daily doses of 1.7, 3.4, 13.8, 44, and 140.8 mg/kg/day (about 0.4 to 34 times the human dose of 40 mg/day expressed on a body surface area basis) produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of omeprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 3.4 times the human dose of 40 mg/day on a body surface area basis) for 1 year, then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of 1 year (94% treated vs. 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs. 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for 2 years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. A 78-week mouse carcinogenicity study of omeprazole did not show increased tumor occurrence, but the study was not conclusive.</paragraph> <paragraph>Esomeprazole was negative in the Ames mutation test, in the <content styleCode="italics">in vivo</content> rat bone marrow cell chromosome aberration test, and the <content styleCode="italics">in vivo</content> mouse micronucleus test. Esomeprazole, however, was positive in the <content styleCode="italics">in vitro</content> human lymphocyte chromosome aberration test. Omeprazole was positive in the <content styleCode="italics">in vitro </content>human lymphocyte chromosome aberration test, the <content styleCode="italics">in vivo</content> mouse bone marrow cell chromosome aberration test, and the <content styleCode="italics">in vivo</content> mouse micronucleus test. </paragraph> <paragraph>The potential effects of esomeprazole on fertility and reproductive performance were assessed using omeprazole studies. Omeprazole at oral doses up to 138 mg/kg/day in rats (about 34 times the human dose of 40 mg/day on a body surface area basis) was found to have no effect on reproductive performance of parental animals.</paragraph> </text> <effectiveTime value="20141219"/> </section> </component> <component> <section ID="rowellsl1309364337994"> <id root="7cd172af-1a23-4e5a-ac6c-33a947174c14"/> <code code="34091-9" codeSystem="2.16.840.1.113883.6.1" displayName="ANIMAL PHARMACOLOGY &amp; OR TOXICOLOGY SECTION"/> <title>13.2 Animal Toxicology and/or Pharmacology</title> <text> <paragraph> <content styleCode="italics">Reproduction Studies</content> </paragraph> <paragraph>Reproduction studies have been performed in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at oral doses up to 86 mg/kg/day (about 42 times an oral human dose of 40 mg on a body surface area basis) and have revealed no evidence of impaired fertility or harm to the fetus due to esomeprazole <content styleCode="italics">[see </content> <content styleCode="italics"> <linkHtml href="#_Ref">Use in Specific Populations (8.1)</linkHtml> </content> <content styleCode="italics">].</content> </paragraph> <paragraph> <content styleCode="italics">Juvenile Animal Study</content> </paragraph> <paragraph>A 28-day toxicity study with a 14-day recovery phase was conducted in juvenile rats with esomeprazole magnesium at doses of 70 to 280 mg /kg/day (about 17 to 68 times a daily oral human dose of 40 mg on a body surface area basis). An increase in the number of deaths at the high dose of 280 mg/kg/day was observed when juvenile rats were administered esomeprazole magnesium from postnatal day 7 through postnatal day 35. In addition, doses equal to or greater than 140 mg/kg/day (about 34 times a daily oral human dose of 40 mg on a body surface area basis), produced treatment-related decreases in body weight (approximately 14%) and body weight gain, decreases in femur weight and femur length, and affected overall growth. Comparable findings described above have also been observed in this study with another esomeprazole salt, esomeprazole strontium, at equimolar doses of esomeprazole.</paragraph> </text> <effectiveTime value="20161220"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="williamsonbk1158778492663"> <id root="c6cac520-5996-4bf0-a2d9-28c7ba1acb23"/> <code code="34092-7" codeSystem="2.16.840.1.113883.6.1" displayName="CLINICAL STUDIES SECTION"/> <title>14 CLINICAL STUDIES</title> <effectiveTime value="20180607"/> <component> <section ID="ID_3d75d1b4-e7af-436e-acbb-186ac7f49f16"> <id root="ed61ef02-3678-4eda-8f05-a7d12faa8395"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.1 Healing of Erosive Esophagitis</title> <text> <paragraph>The healing rates of NEXIUM 40 mg, NEXIUM 20 mg, and omeprazole 20 mg (the approved dose for this indication) were evaluated in patients with endoscopically diagnosed erosive esophagitis in four multicenter, double-blind, randomized studies. The healing rates at Weeks 4 and 8 were evaluated and are shown in the Table 9:</paragraph> <table width="100%"> <caption>Table 9: Erosive Esophagitis Healing Rate (Life-Table Analysis)</caption> <col width="10%"/> <col width="19%"/> <col width="24%"/> <col width="12%"/> <col width="12%"/> <col width="24%"/> <tbody> <tr> <td styleCode="Botrule Toprule " valign="top"> <paragraph> Study</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph>No. of Patients</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph> Treatment Groups</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph> Week 4</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph> Week 8</paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph>Significance Level<footnote ID="_RefFN1158779825-1"> log-rank test vs. omeprazole 20 mg.</footnote> </paragraph> </td> </tr> <tr> <td align="center" valign="top"> <paragraph>1</paragraph> </td> <td align="center" valign="top"> <paragraph>588</paragraph> </td> <td valign="top"> <paragraph>NEXIUM 20 mg</paragraph> </td> <td align="center" valign="top"> <paragraph>68.7%</paragraph> </td> <td align="center" valign="top"> <paragraph>90.6%</paragraph> </td> <td valign="top"> <paragraph>N.S. </paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td align="center" styleCode="Botrule " valign="top"> <paragraph>588</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>69.5%</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>88.3%</paragraph> </td> <td styleCode="Botrule " valign="top"/> </tr> <tr> <td align="center" valign="top"> <paragraph>2</paragraph> </td> <td align="center" valign="top"> <paragraph>654</paragraph> </td> <td valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" valign="top"> <paragraph>75.9%</paragraph> </td> <td align="center" valign="top"> <paragraph>94.1%</paragraph> </td> <td valign="top"> <paragraph>p &lt; 0.001</paragraph> </td> </tr> <tr> <td valign="top"/> <td align="center" valign="top"> <paragraph>656</paragraph> </td> <td valign="top"> <paragraph>NEXIUM 20 mg</paragraph> </td> <td align="center" valign="top"> <paragraph>70.5%</paragraph> </td> <td align="center" valign="top"> <paragraph>89.9%</paragraph> </td> <td valign="top"> <paragraph>p &lt; 0.05</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td align="center" styleCode="Botrule " valign="top"> <paragraph>650</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>64.7%</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>86.9%</paragraph> </td> <td styleCode="Botrule " valign="top"/> </tr> <tr> <td align="center" valign="top"> <paragraph>3</paragraph> </td> <td align="center" valign="top"> <paragraph>576</paragraph> </td> <td valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" valign="top"> <paragraph>71.5%</paragraph> </td> <td align="center" valign="top"> <paragraph>92.2%</paragraph> </td> <td valign="top"> <paragraph>N.S. </paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td align="center" styleCode="Botrule " valign="top"> <paragraph>572</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>68.6%</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>89.8%</paragraph> </td> <td styleCode="Botrule " valign="top"/> </tr> <tr> <td align="center" valign="top"> <paragraph>4</paragraph> </td> <td align="center" valign="top"> <paragraph>1216</paragraph> </td> <td valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" valign="top"> <paragraph>81.7%</paragraph> </td> <td align="center" valign="top"> <paragraph>93.7%</paragraph> </td> <td valign="top"> <paragraph>p &lt; 0.001</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td align="center" styleCode="Botrule " valign="top"> <paragraph>1209</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>68.7%</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>84.2%</paragraph> </td> <td styleCode="Botrule " valign="top"/> </tr> <tr> <td colspan="6" styleCode="Toprule " valign="top"> <paragraph>N.S. = not significant (p &gt; 0.05).</paragraph> </td> </tr> </tbody> </table> <paragraph>In these same studies of patients with erosive esophagitis, sustained heartburn resolution and time to sustained heartburn resolution were evaluated and are shown in the Table 10:</paragraph> <table width="100%"> <caption>Table 10: Sustained Resolution<footnote ID="_RefFN1158780524-1">Defined as 7 consecutive days with no heartburn reported in daily patient diary.</footnote> of Heartburn (Erosive Esophagitis Patients)</caption> <col width="7%"/> <col width="15%"/> <col width="18%"/> <col width="21%"/> <col width="21%"/> <col width="19%"/> <tbody> <tr> <td styleCode="Botrule Lrule Toprule " valign="top"/> <td styleCode="Botrule Lrule Toprule " valign="top"/> <td styleCode="Botrule Lrule Toprule " valign="top"/> <td colspan="2" styleCode="Botrule Lrule Toprule " valign="top"> <paragraph>Cumulative Percent<footnote ID="_RefFN1158780390-1">Defined as the cumulative proportion of patients who have reached the start of sustained resolution.</footnote> with Sustained Resolution</paragraph> </td> <td styleCode="Rrule Botrule Lrule Toprule " valign="top"/> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Study</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>No. of Patients</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Treatment Groups</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>Day 14</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>Day 28</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>Significance Level<footnote ID="_RefFN1158939502-1">log-rank test vs. omeprazole 20 mg.</footnote> </paragraph> </td> </tr> <tr> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>573</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>64.3%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>72.7%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>N.S. </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>555</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>64.1%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>70.9%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"/> </tr> <tr> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>2</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>621</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>64.8%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>74.2%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>p &lt;0.001</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>620</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>62.9%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>70.1%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>N.S. </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>626</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>56.5%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>66.6%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"/> </tr> <tr> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>3</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>568</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>65.4%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>73.9%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>N.S. </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>551</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>65.5%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>73.1%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"/> </tr> <tr> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>4</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1187</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 40 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>67.6%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>75.1%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>p &lt;0.001</paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"/> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>1188</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>Omeprazole 20 mg</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>62.5%</paragraph> </td> <td align="center" styleCode="Lrule Botrule " valign="top"> <paragraph>70.8%</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"/> </tr> <tr> <td colspan="6" styleCode="Toprule " valign="top"> <paragraph>N.S. = not significant (p&gt; 0.05)</paragraph> </td> </tr> </tbody> </table> <paragraph>In these four studies, the range of median days to the start of sustained resolution (defined as 7 consecutive days with no heartburn) was 5 days for NEXIUM 40 mg, 7 to 8 days for NEXIUM 20 mg and 7 to 9 days for omeprazole 20 mg.</paragraph> <paragraph>There are no comparisons of 40 mg of NEXIUM with 40 mg of omeprazole in clinical trials assessing either healing or symptomatic relief of erosive esophagitis.</paragraph> <paragraph> <content styleCode="italics">Long-Term Maintenance of Healing of Erosive Esophagitis </content> </paragraph> <paragraph>Two multicenter, randomized, double-blind placebo-controlled 4-arm trials were conducted in patients with endoscopically confirmed, healed erosive esophagitis to evaluate NEXIUM 40 mg (n=174), 20 mg (n=180), 10 mg (n=168) or placebo (n=171) once daily over six months of treatment. </paragraph> <paragraph>No additional clinical benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. </paragraph> <paragraph>The percentages of patients that maintained healing of erosive esophagitis at the various time points are shown in the Figures 2 and 3:</paragraph> <paragraph> <content styleCode="bold">Figure 2: Maintenance of Healing Rates by Month (Study 177)</content> </paragraph> <renderMultiMedia ID="id3349" referencedObject="ED189E6D-5895-4C6C-8E7C-F234925126BD"/> <paragraph>s= scheduled visit</paragraph> <paragraph> <content styleCode="bold">Figure 3: Maintenance of Healing Rates by Month (Study 178)</content> </paragraph> <renderMultiMedia ID="id3353" referencedObject="D7FC6FE1-3185-4E75-AA09-442D42A392E6"/> <paragraph>s= scheduled visit</paragraph> <paragraph>Patients remained in remission significantly longer and the number of recurrences of erosive esophagitis was significantly less in patients treated with NEXIUM compared to placebo. </paragraph> <paragraph>In both studies, the proportion of patients on NEXIUM who remained in remission and were free of heartburn and other GERD symptoms was well differentiated from placebo.</paragraph> <paragraph>In a third multicenter open label study of 808 patients treated for 12 months with NEXIUM 40 mg, the percentage of patients that maintained healing of erosive esophagitis was 93.7% for six months and 89.4% for one year.</paragraph> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ED189E6D-5895-4C6C-8E7C-F234925126BD"> <text>Figure 2 Maintenance of Healing Rates by Month (Study 117)</text> <value mediaType="image/jpeg"> <reference value="image-02.jpg"/> </value> </observationMedia> </component> <component> <observationMedia ID="D7FC6FE1-3185-4E75-AA09-442D42A392E6"> <text>Figure 3 Maintenance of Healing Rates by Month (Study 178)</text> <value mediaType="image/jpeg"> <reference value="image-03.jpg"/> </value> </observationMedia> </component> </section> </component> <component> <section ID="williamsonbk1185473675741"> <id root="b3453dea-ea48-4b1b-bad6-c5e0f82eb990"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.2 Symptomatic Gastroesophageal Reflux Disease (GERD)</title> <text> <paragraph>Two multicenter, randomized, double-blind, placebo-controlled studies were conducted in a total of 717 patients comparing four weeks of treatment with NEXIUM 20 mg or 40 mg once daily versus placebo for resolution of GERD symptoms. Patients had ≥ 6-month history of heartburn episodes, no erosive esophagitis by endoscopy, and heartburn on at least four of the seven days immediately preceding randomization.</paragraph> <paragraph>The percentage of patients that were symptom-free of heartburn was significantly higher in the NEXIUM groups compared to placebo at all follow-up visits (Weeks 1, 2, and 4). </paragraph> <paragraph>No additional clinical benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. </paragraph> <paragraph>The percent of patients symptom-free of heartburn by day are shown in the Figures 4 and 5:</paragraph> <paragraph> <content styleCode="bold">Figure 4: Percent of Patients Symptom-Free of Heartburn by Day (Study 225)</content> </paragraph> <renderMultiMedia ID="id3384" referencedObject="ID_5bdc19b9-afa8-4409-97e0-63e4d24ee6d0"/> <paragraph> <content styleCode="bold">Figure 5: Percent of Patients Symptom-Free of Heartburn by Day (Study 226)</content> </paragraph> <renderMultiMedia ID="id3390" referencedObject="ID_4a92cfcc-818e-430e-8b72-8678bcd6d35e"/> <paragraph>In three European symptomatic GERD trials, NEXIUM 20 mg and 40 mg and omeprazole 20 mg were evaluated. No significant treatment related differences were seen.</paragraph> </text> <effectiveTime value="20141219"/> <component> <observationMedia ID="ID_5bdc19b9-afa8-4409-97e0-63e4d24ee6d0"> <text>Figure 4 Percent of Patients Symptom-Free of Heartburn by Day (Study 225)</text> <value mediaType="image/jpeg"> <reference value="image-04.jpg"/> </value> </observationMedia> </component> <component> <observationMedia ID="ID_4a92cfcc-818e-430e-8b72-8678bcd6d35e"> <text>Figure 5 Percent of Patients Symptom-Free of Heartburn by Day (Study 226)</text> <value mediaType="image/jpeg"> <reference value="image-05.jpg"/> </value> </observationMedia> </component> </section> </component> <component> <section ID="williamsonbk1185378883110"> <id root="efd19577-fd83-4bad-8918-e78e9cde727b"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.3 Pediatric Gastroesophageal Reflux Disease (GERD)</title> <text> <paragraph> <content styleCode="italics">1 to 11 Years of Age</content> </paragraph> <paragraph>In a multicenter, parallel-group study, 109 pediatric patients with a history of endoscopically-proven GERD (1 to 11 years of age; 53 female; 89 Caucasian, 19 Black, 1 Other) were treated with NEXIUM once daily for up to 8 weeks to evaluate safety and tolerability. Dosing by patient weight was as follows:</paragraph> <list listType="unordered"> <item> <caption> </caption>weight &lt; 20 kg: once daily treatment with NEXIUM 5 mg or 10 mg </item> <item> <caption> </caption>weight ≥ 20 kg: once daily treatment with NEXIUM 10 mg or 20 mg </item> </list> <paragraph>Patients were endoscopically characterized as to the presence or absence of erosive esophagitis. </paragraph> <paragraph>Of the 109 patients, 53 had erosive esophagitis at baseline (51 had mild, 1 moderate, and 1 severe esophagitis). Although most of the patients who had a follow up endoscopy at the end of 8 weeks of treatment healed, spontaneous healing cannot be ruled out because these patients had low grade erosive esophagitis prior to treatment, and the trial did not include a concomitant control.</paragraph> <paragraph> <content styleCode="italics">12 to 17 Years of Age </content> </paragraph> <paragraph>In a multicenter, randomized, double-blind, parallel-group study, 149 adolescent patients (12 to 17 years of age; 89 female; 124 Caucasian, 15 Black, 10 Other) with clinically diagnosed GERD were treated with either NEXIUM 20 mg or NEXIUM 40 mg once daily for up to 8 weeks to evaluate safety and tolerability. Patients were not endoscopically characterized as to the presence or absence of erosive esophagitis.</paragraph> </text> <effectiveTime value="20160125"/> </section> </component> <component> <section ID="ID_da3538dd-f862-41c0-97c2-28078ff8affd"> <id root="5240899e-6647-4132-8628-e9b3423f1b58"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.4 Risk Reduction of NSAID-Associated Gastric Ulcer</title> <text> <paragraph>Two multicenter, double-blind, placebo-controlled studies were conducted in patients at risk of developing gastric and/or duodenal ulcers associated with continuous use of non-selective and COX-2 selective NSAIDs. A total of 1429 patients were randomized across the 2 studies. Patients ranged in age from 19 to 89 (median age 66.0 years) with 70.7% female, 29.3% male, 82.9% Caucasian, 5.5% Black, 3.7% Asian, and 8.0% Others. At baseline, the patients in these studies were endoscopically confirmed not to have ulcers but were determined to be at risk for ulcer occurrence due to their age (≥60 years) and/or history of a documented gastric or duodenal ulcer within the past 5 years. Patients receiving NSAIDs and treated with NEXIUM 20 mg or 40 mg once-a-day experienced significant reduction in gastric ulcer occurrences relative to placebo treatment at 26 weeks. See Table 11. No additional benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. These studies did not demonstrate significant reduction in the development of NSAID-associated duodenal ulcer due to the low incidence.</paragraph> <table width="100%"> <caption>Table 11: Cumulative Percentage of Patients without Gastric Ulcers at 26 Weeks</caption> <col width="9%"/> <col width="19%"/> <col width="21%"/> <col width="51%"/> <tbody> <tr> <td styleCode="Botrule Lrule Toprule " valign="top"> <paragraph>Study</paragraph> </td> <td styleCode="Botrule Lrule Toprule " valign="top"> <paragraph>No. of Patients</paragraph> </td> <td styleCode="Botrule Lrule Toprule " valign="top"> <paragraph>Treatment Group</paragraph> </td> <td styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph>% of Patients Remaining Gastric Ulcer Free<footnote ID="_RefFN1158780669-1">%= Life Table Estimate. Significant difference from placebo (p&lt;0.01).</footnote> </paragraph> </td> </tr> <tr> <td styleCode="Lrule Botrule " valign="top"> <paragraph>1</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>191</paragraph> <paragraph>194</paragraph> <paragraph>184</paragraph> </td> <td styleCode="Lrule Botrule " valign="top"> <paragraph>NEXIUM 20 mg</paragraph> <paragraph>NEXIUM 40 mg</paragraph> <paragraph>Placebo</paragraph> </td> <td styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>95.4</paragraph> <paragraph>96.7</paragraph> <paragraph>88.2</paragraph> </td> </tr> <tr> <td styleCode="Botrule Lrule " valign="top"> <paragraph>2</paragraph> </td> <td styleCode="Botrule Lrule " valign="top"> <paragraph>267</paragraph> <paragraph>271</paragraph> <paragraph>257</paragraph> </td> <td styleCode="Botrule Lrule " valign="top"> <paragraph>NEXIUM 20 mg</paragraph> <paragraph>NEXIUM 40 mg</paragraph> <paragraph>Placebo</paragraph> </td> <td styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>94.7</paragraph> <paragraph>95.3</paragraph> <paragraph>83.3</paragraph> </td> </tr> </tbody> </table> </text> <effectiveTime value="20161220"/> </section> </component> <component> <section ID="ID_9e223778-3f04-4a7c-9314-048ebd9e15d9"> <id root="80fa7807-4787-4586-9cb5-db7c358e2bf6"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.5 <content styleCode="italics">Helicobacter pylori (H. pylori)</content> Eradication in Patients with Duodenal Ulcer Disease</title> <text> <paragraph> <content styleCode="italics">Triple Therapy (NEXIUM/amoxicillin/clarithromycin):</content> Two multicenter, randomized, double-blind studies were conducted using a 10 day treatment regimen. The first study (191) compared NEXIUM 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to NEXIUM 40 mg once daily plus clarithromycin 500 mg twice daily. The second study (193) compared NEXIUM 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to NEXIUM 40 mg once daily. <content styleCode="italics">H. pylori</content> eradication rates, defined as at least two negative tests and no positive tests from CLOtest^®, histology and/or culture, at 4 weeks post-therapy were significantly higher in the NEXIUM plus amoxicillin and clarithromycin group than in the NEXIUM plus clarithromycin or NEXIUM alone group. The results are shown in Table 12:</paragraph> <table width="100%"> <caption>Table 12: H. pylori Eradication Rates at 4 Weeks after 10 Day Treatment Regimen % of Patients Cured [95% Confidence Interval] (Number of Patients)</caption> <col width="9%"/> <col width="54%"/> <col width="17%"/> <col width="20%"/> <tbody> <tr> <td align="center" styleCode="Botrule Toprule " valign="top"> <paragraph>Study</paragraph> </td> <td align="center" styleCode="Botrule Toprule " valign="top"> <paragraph>Treatment Group</paragraph> </td> <td align="center" styleCode="Botrule Toprule " valign="top"> <paragraph>Per-Protocol<footnote ID="_Ref338392934">Patients were included in the analysis if they had <content styleCode="italics">H. pylori</content> infection documented at baseline, had at least one endoscopically verified duodenal ulcer ≥ 0.5 cm in diameter at baseline or had a documented history of duodenal ulcer disease within the past 5 years, and were not protocol violators. Patients who dropped out of the study due to an adverse reaction related to the study drug were included in the analysis as not <content styleCode="italics">H. pylori </content>eradicated.</footnote> </paragraph> </td> <td styleCode="Botrule Toprule " valign="top"> <paragraph>Intent-to-Treat<footnote ID="_Ref338393167">Patients were included in the analysis if they had documented <content styleCode="italics">H. pylori</content> infection at baseline, had at least one documented duodenal ulcer at baseline, or had a documented history of duodenal ulcer disease, and took at least one dose of study medication. All dropouts were included as not <content styleCode="italics">H. pylori</content> eradicated.</footnote> </paragraph> </td> </tr> <tr> <td align="center" styleCode="Botrule " valign="top"> <paragraph>191</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>NEXIUM plus amoxicillin and clarithromycin </paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>84%<footnote ID="_Ref338393337"> p &lt; 0.05 compared to NEXIUM plus clarithromycin.</footnote> </paragraph> <paragraph>[78, 89]</paragraph> <paragraph>(n=196)</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>77%<footnoteRef IDREF="_Ref338393337"/> </paragraph> <paragraph>[71, 82]</paragraph> <paragraph>(n=233)</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td styleCode="Botrule " valign="top"> <paragraph>NEXIUM plus clarithromycin</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>55%</paragraph> <paragraph>[48, 62]</paragraph> <paragraph>(n=187)</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>52%</paragraph> <paragraph>[45, 59]</paragraph> <paragraph>(n=215)</paragraph> </td> </tr> <tr> <td align="center" styleCode="Botrule " valign="top"> <paragraph>193</paragraph> </td> <td styleCode="Botrule " valign="top"> <paragraph>NEXIUM plus amoxicillin and clarithromycin </paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>85%<footnote ID="_Ref338393384"> p &lt; 0.05 compared to NEXIUM alone.</footnote> </paragraph> <paragraph>[74, 93]</paragraph> <paragraph>(n=67)</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>78%<footnoteRef IDREF="_Ref338393384"/> </paragraph> <paragraph>[67, 87]</paragraph> <paragraph>(n=74)</paragraph> </td> </tr> <tr> <td styleCode="Botrule " valign="top"/> <td styleCode="Botrule " valign="top"> <paragraph>NEXIUM</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>5%</paragraph> <paragraph>[0, 23]</paragraph> <paragraph>(n=22)</paragraph> </td> <td align="center" styleCode="Botrule " valign="top"> <paragraph>4%</paragraph> <paragraph>[0, 21]</paragraph> <paragraph>(n=24)</paragraph> </td> </tr> </tbody> </table> <paragraph>The percentage of patients with a healed baseline duodenal ulcer by 4 weeks after the 10 day treatment regimen in the NEXIUM plus amoxicillin and clarithromycin group was 75% (n=156) and 57% (n=60) respectively, in the 191 and 193 studies (per-protocol analysis). </paragraph> </text> <effectiveTime value="20160125"/> </section> </component> <component> <section ID="williamsonbk1324409481884"> <id root="f370eed3-54c8-4987-8a85-db046f44ee8a"/> <code code="42229-5" codeSystem="2.16.840.1.113883.6.1" displayName="SPL UNCLASSIFIED SECTION"/> <title>14.6 Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome</title> <text> <paragraph>In a multicenter, open-label dose-escalation study of 21 patients (15 males and 6 females, 18 Caucasian and 3 Black, mean age of 55.5 years) with pathological hypersecretory conditions, such as Zollinger-Ellison Syndrome, NEXIUM significantly inhibited gastric acid secretion. Initial dose was 40 mg twice daily in 19/21 patients and 80 mg twice daily in 2/21 patients. Total daily doses ranging from 80 mg to 240 mg for 12 months maintained gastric acid output below the target levels of 10 mEq/h in patients without prior gastric acid-reducing surgery and below 5 mEq/hr in patients with prior gastric acid-reducing surgery. At the Month 12 final visit, 18/20 (90%) patients had Basal Acid Output (BAO) under satisfactory control (median BAO = 0.17 mmol/hr). Of the 18 patients evaluated with a starting dose of 40 mg twice daily, 13 (72%) had their BAO controlled with the original dosing regimen at the final visit. See Table 13.</paragraph> <table ID="_RefID0E66CI" width="100%"> <caption>Table 13: Adequate Acid Suppression at Final Visit by Dose Regimen</caption> <col width="39%"/> <col width="61%"/> <tbody> <tr> <td align="center" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph>NEXIUM dose at the Month 12 visit</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule Toprule " valign="top"> <paragraph>BAO under adequate control at the Month 12 visit (N=20)<footnote ID="_Ref338327759">One patient was not evaluated.</footnote> </paragraph> </td> </tr> <tr> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>40 mg twice daily</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>13/15</paragraph> </td> </tr> <tr> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>80 mg twice daily</paragraph> </td> <td align="center" styleCode="Rrule Lrule Botrule " valign="top"> <paragraph>4/4</paragraph> </td> </tr> <tr> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>80 mg three times daily</paragraph> </td> <td align="center" styleCode="Rrule Botrule Lrule " valign="top"> <paragraph>1/1</paragraph> </td> </tr> </tbody> </table> </text> <effectiveTime value="20160125"/> </section> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_1a9ef701-dc35-481f-8163-89545f658ad4"> <id root="3bc4146d-c904-45af-a8e7-27eb74bec200"/> <code code="34069-5" codeSystem="2.16.840.1.113883.6.1" displayName="HOW SUPPLIED SECTION"/> <title>16 HOW SUPPLIED/STORAGE AND HANDLING</title> <text> <paragraph>NEXIUM Delayed-Release Capsules, 20 mg, are opaque, hard gelatin, amethyst colored capsules with two radial bars in yellow on the cap and NEXIUM 20 mg in yellow on the body. They are supplied as follows:</paragraph> <paragraph>NDC 0186-5020-31 unit of use bottles of 30</paragraph> <paragraph>NDC 0186-5020-54 bottles of 90</paragraph> <paragraph>NDC 0186-5020-82 bottles of 1000</paragraph> <paragraph>NEXIUM Delayed-Release Capsules, 40 mg, are opaque, hard gelatin, amethyst colored capsules with three radial bars in yellow on the cap and NEXIUM 40 mg in yellow on the body. They are supplied as follows:</paragraph> <paragraph>NDC 0186-5040-31 unit of use bottles of 30</paragraph> <paragraph>NDC 0186-5040-54 bottles of 90</paragraph> <paragraph>NDC 0186-5040-82 bottles of 1000</paragraph> <paragraph>NEXIUM For Delayed-Release Oral Suspension is supplied as a unit dose packet containing a fine yellow powder, consisting of white to pale brownish esomeprazole granules and pale yellow inactive granules. NEXIUM unit dose packets are supplied as follows:</paragraph> <paragraph>NDC 0186-4025-01 unit dose packages of 30: 2.5 mg packets</paragraph> <paragraph>NDC 0186-4050-01 unit dose packages of 30: 5 mg packets</paragraph> <paragraph>NDC 0186-4010–01 unit dose packages of 30: 10 mg packets</paragraph> <paragraph>NDC 0186-4020–01 unit dose packages of 30: 20 mg packets</paragraph> <paragraph>NDC 0186-4040–01 unit dose packages of 30: 40 mg packets</paragraph> <paragraph>Store at 25°C (77°F); excursions permitted to 15 to 30°C (59 to 86°F). [See USP Controlled Room Temperature]. Keep NEXIUM Delayed-Release Capsules container tightly closed. Dispense in a tight container if the NEXIUM Delayed-Release Capsules product package is subdivided.</paragraph> </text> <effectiveTime value="20160714"/> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_cea46bed-a35d-4109-843c-a4257fa29e39"> <id root="bf8f9e42-17a7-43d4-a156-47ad073b70a7"/> <code code="34076-0" codeSystem="2.16.840.1.113883.6.1" displayName="INFORMATION FOR PATIENTS SECTION"/> <title>17 PATIENT COUNSELING INFORMATION</title> <text> <paragraph>Advise the patient to read the FDA-approved patient labeling (Medication Guide).</paragraph> <paragraph>Adverse Reactions</paragraph> <paragraph>Advise patients to report to their healthcare provider if they experience any signs or symptoms consistent with:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Hypersensitivity Reactions <content styleCode="italics">[see <linkHtml href="#williamsonbk1158777746710">Contraindications (4)</linkHtml>]</content> </item> <item> <caption>•</caption>Acute Interstitial Nephritis <content styleCode="italics">[see <linkHtml href="#ID_adf7e4c9-9f73-40ac-baad-06bc92770930">Warnings and Precautions (5.2)</linkHtml>]</content> </item> <item> <caption>•</caption>Clostridium difficile-Associated Diarrhea <content styleCode="italics">[see <linkHtml href="#ID_6b0e1800-d077-49ac-851c-d3422efeaa8f">Warnings and Precautions (5.3)</linkHtml>]</content> </item> <item> <caption>•</caption>Bone Fracture <content styleCode="italics">[see <linkHtml href="#williamsonbk1282066915764">Warnings and Precaution (5.4)</linkHtml>]</content> </item> <item> <caption>•</caption>Cutaneous and Systemic Lupus Erythematosus <content styleCode="italics">[see <linkHtml href="#ID_9c98abad-7d2d-45c4-9b79-952629467d42">Warnings and Precautions (5.5)</linkHtml>]</content> </item> <item> <caption>•</caption>Cyanocobalamin (Vitamin B-12) Deficiency <content styleCode="italics">[see <linkHtml href="#ID_b13ac510-713a-4b92-b387-61a7d97aefd7">Warnings and Precautions (5.7)</linkHtml>]</content> </item> <item> <caption>•</caption>Hypomagnesemia <content styleCode="italics">[see <linkHtml href="#ID_99eafb44-c0ea-451c-9dba-722cfeaf9050">Warnings and Precautions (5.8)</linkHtml>]</content> </item> </list> <paragraph>Drug Interactions</paragraph> <list listType="unordered"> <item> <caption>•</caption>Advise patients to let you know if they are taking, or begin taking, other medications, because NEXIUM can interfere with antiretroviral drugs and drugs that are affected by gastric pH changes [see <linkHtml href="#ID_88dd184a-fc0c-45f8-8f5d-ac9c96390c2b">Drug Interactions (7.1)</linkHtml>].</item> </list> <paragraph>Administration</paragraph> <list listType="unordered"> <item> <caption>•</caption>Let patients know that antacids may be used while taking NEXIUM.</item> <item> <caption>•</caption>Advise patients to take NEXIUM at least one hour before a meal. </item> <item> <caption>•</caption>For patients who are prescribed NEXIUM Delayed-Release Capsules, advise them not to chew or crush the capsules. </item> <item> <caption>•</caption>Advise patients that, if they open NEXIUM Delayed-Release Capsules to mix the granules with food, the granules should only be mixed with applesauce. Use with other foods has not been evaluated and is not recommended.</item> <item> <caption>•</caption>For patients who are advised to open the NEXIUM Delayed-Release Capsules before taking them or who are prescribed NEXIUM For Delayed-Release Oral Suspension, instruct them in the proper technique for administration [see <linkHtml href="#williamsonbk1158841553901">Dosage and Administration (2)</linkHtml>] and tell them to follow the dosing instructions in the PATIENT INFORMATION insert included in the package. Instruct patients to rinse the syringe with water after each use.</item> <item> <caption>•</caption>For patients who are prescribed NEXIUM For Delayed-Release Oral Suspension and need to use more than one packet for their dose, instruct them regarding the correct amount of water to use when mixing their dose.</item> </list> <paragraph>Distributed by: </paragraph> <paragraph>AstraZeneca Pharmaceuticals LP </paragraph> <paragraph>Wilmington, DE 19850 </paragraph> <paragraph>NEXIUM and the color purple as applied to the capsule are registered trademarks of the AstraZeneca group of companies. </paragraph> <paragraph>©AstraZeneca 2018</paragraph> </text> <effectiveTime value="20180607"/> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_f52a1edd-c487-4ae0-8156-bb8d1b7f5327"> <id root="03eb754e-1403-454b-af01-a7c832c7b51f"/> <code code="42231-1" codeSystem="2.16.840.1.113883.6.1" displayName="SPL MEDGUIDE SECTION"/> <title>MEDICATION GUIDE</title> <text> <paragraph> <content styleCode="bold">NEXIUM^® (nex-e-um) </content> </paragraph> <paragraph> <content styleCode="bold">(esomeprazole magnesium) </content> </paragraph> <paragraph> <content styleCode="bold">Delayed-Release Capsules</content> </paragraph> <paragraph> <content styleCode="bold">NEXIUM^® (nex-e-um)</content> </paragraph> <paragraph> <content styleCode="bold">(esomeprazole magnesium) </content> </paragraph> <paragraph> <content styleCode="bold">For Delayed-Release </content> <br/> <content styleCode="bold">Oral Suspension</content> </paragraph> <paragraph>Read the Medication Guide that comes with NEXIUM before you start taking NEXIUM and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment.</paragraph> <paragraph> <content styleCode="bold">What is the most important information I should know about NEXIUM?</content> </paragraph> <paragraph> <content styleCode="bold">NEXIUM may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor. </content> </paragraph> <paragraph> <content styleCode="bold">NEXIUM can cause serious side effects, including:</content> </paragraph> <list listType="unordered"> <item> <caption>•</caption> <content styleCode="bold">A type of kidney problem (acute interstitial nephritis)</content>. Some people who take proton pump inhibitor (PPI) medicines, including NEXIUM, may develop a kidney problem called acute interstitial nephritis that can happen at any time during treatment with NEXIUM. Call your doctor if you have a decrease in the amount that you urinate or if you have blood in your urine.</item> <item> <caption>•</caption> <content styleCode="bold">Diarrhea.</content> NEXIUM may increase your risk of getting severe diarrhea. This diarrhea may be caused by an infection (Clostridium difficile) in your intestines. <br/>Call your doctor right away if you have watery stool, stomach pain, and fever that does not go away.</item> <item> <caption>•</caption> <content styleCode="bold">Bone fractures.</content> People who take multiple daily doses of PPI medicines for a long period of time (a year or longer) may have an increased risk of fractures of the hip, wrist, or spine. You should take NEXIUM exactly as prescribed, at the lowest dose possible for your treatment and for the shortest time needed. Talk to your doctor about your risk of bone fracture if you take NEXIUM.</item> <item> <caption>•</caption> <content styleCode="bold">Certain types of lupus erythematosus.</content> Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including NEXIUM, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.</item> </list> <paragraph>NEXIUM can have other serious side effects. See “<content styleCode="bold">What are the possible side effects of NEXIUM</content>?”</paragraph> <paragraph> <content styleCode="bold">What is NEXIUM?</content> </paragraph> <paragraph>NEXIUM is a prescription medicine called a proton pump inhibitor (PPI). NEXIUM reduces the amount of acid in your stomach.</paragraph> <paragraph>NEXIUM is used in adults:</paragraph> <list listType="unordered"> <item> <caption>•</caption>for 4 to 8 weeks to treat the symptoms of gastroesophageal reflux disease (GERD). NEXIUM may also be prescribed to heal acid-related damage to the lining of the esophagus (erosive esophagitis), and to help continue this healing. <br/>GERD happens when acid in your stomach backs up into the tube (esophagus) that connects your mouth to your stomach. This may cause a burning feeling in your chest or throat, sour taste, or burping.</item> <item> <caption>•</caption>for up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs).</item> <item> <caption>•</caption>to treat patients with a stomach infection (<content styleCode="italics">Helicobacter pylori</content>), along with the antibiotics amoxicillin and clarithromycin.</item> <item> <caption>•</caption>for the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid.</item> </list> <paragraph>For children and adolescents 1 year to 17 years of age, NEXIUM may be prescribed for up to 8 weeks for short-term treatment of GERD.</paragraph> <paragraph>In children ages 1 month to less than 1 year of age, NEXIUM is only used to treat GERD with acid-related damage to the esophagus (erosive esophagitis) for up to 6 weeks.</paragraph> <paragraph>It is not known if NEXIUM is effective in children under 1 month of age.</paragraph> <paragraph> <content styleCode="bold">Who should not take NEXIUM?</content> </paragraph> <paragraph>Do not take NEXIUM if you:</paragraph> <list listType="unordered"> <item> <caption>•</caption>are allergic to esomeprazole magnesium or any of the ingredients in NEXIUM. See the end of this Medication Guide for a complete list of ingredients in NEXIUM.</item> <item> <caption>•</caption>are allergic to any other PPI medicine. </item> </list> <paragraph> <content styleCode="bold">What should I tell my doctor before taking NEXIUM?</content> </paragraph> <paragraph> <content styleCode="bold">Before you take NEXIUM, tell your doctor if you:</content> </paragraph> <list listType="unordered"> <item> <caption>•</caption>have been told that you have low magnesium levels in your blood.</item> <item> <caption>•</caption>have liver problems.</item> <item> <caption>•</caption>are pregnant or plan to become pregnant. It is not known if NEXIUM can harm your unborn baby.</item> <item> <caption>•</caption>are breastfeeding or planning to breastfeed. NEXIUM may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take NEXIUM.</item> </list> <paragraph> <content styleCode="bold">Tell your doctor about all of the medicines you take</content>, including prescription and non-prescription drugs, vitamins and herbal supplements. NEXIUM may affect how other medicines work, and other medicines may affect how NEXIUM works. </paragraph> <paragraph>Especially tell your doctor if you take:</paragraph> <table width="100%"> <col width="50%"/> <col width="50%"/> <tbody> <tr styleCode="Toprule"> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>warfarin (Coumadin, Jantoven)</item> <item> <caption>•</caption>ketoconazole (Nizoral)</item> <item> <caption>•</caption>voriconazole (Vfend)</item> <item> <caption>•</caption>atazanavir (Reyataz)</item> <item> <caption>•</caption>nelfinavir (Viracept)</item> <item> <caption>•</caption>saquinavir (Fortovase)</item> <item> <caption>•</caption>products that contain iron </item> <item> <caption>•</caption>digoxin (Lanoxin)</item> <item> <caption>•</caption>St. John’s Wort (Hypericum perforatum)</item> </list> </td> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>Rifampin (Rimactane, Rifater, Rifamate)</item> <item> <caption>•</caption>cilostazol (Pletal) </item> <item> <caption>•</caption>diazepam (Valium) </item> <item> <caption>•</caption>tacrolimus (Prograf)</item> <item> <caption>•</caption>erlotinib (Tarceva)</item> <item> <caption>•</caption>methotrexate</item> <item> <caption>•</caption>clopidogrel (Plavix)</item> <item> <caption>•</caption>mycophenolate mofetil (Cellcept)</item> </list> </td> </tr> </tbody> </table> <paragraph> <content styleCode="bold">How should I take NEXIUM?</content> </paragraph> <list listType="unordered"> <item> <caption>•</caption>Take NEXIUM exactly as prescribed by your doctor. </item> <item> <caption>•</caption>Do not change your dose or stop NEXIUM without talking to your doctor.</item> <item> <caption>•</caption>Take NEXIUM at least 1 hour before a meal.</item> <item> <caption>•</caption>Swallow NEXIUM capsules whole. <content styleCode="bold">Never chew or crush NEXIUM.</content> </item> <item> <caption>•</caption>If you have difficulty swallowing NEXIUM capsules, you may open the capsule and empty the contents into a tablespoon of applesauce. Do not crush or chew the granules. Be sure to swallow the applesauce right away. Do not store it for later use.</item> <item> <caption>•</caption>If you forget to take a dose of NEXIUM, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose. </item> <item> <caption>•</caption>If you take too much NEXIUM, call your doctor or local poison control center right away, or go to the nearest hospital emergency room. </item> <item> <caption>•</caption>See the “Instructions for Use” at the end of this Medication Guide for instructions how to take NEXIUM For Delayed-Release Oral Suspension, and how to mix and give NEXIUM Delayed-Release Capsules and NEXIUM For Delayed-Release Oral Suspension, through a nasogastric tube or gastric tube.</item> </list> <paragraph> <content styleCode="bold">What are the possible side effects of NEXIUM?</content> </paragraph> <paragraph> <content styleCode="bold">NEXIUM can cause serious side effects, including: </content> </paragraph> <list listType="unordered"> <item> <caption>•</caption> <content styleCode="bold">See “What is the most important information I should know about NEXIUM?”</content> </item> <item> <caption>•</caption> <content styleCode="bold">Vitamin B-12 deficiency.</content> NEXIUM reduces the amount of acid in your stomach. Stomach acid is needed to absorb vitamin B-12 properly. Talk with your doctor about the possibility of vitamin B-12 deficiency if you have been on NEXIUM for a long time (more than 3 years).</item> <item> <caption>•</caption> <content styleCode="bold">Low magnesium levels in your body.</content> Low magnesium can happen in some people who take a PPI medicine for at least 3 months. If low magnesium levels happen, it is usually after a year of treatment. </item> <item> <caption> </caption>You may or may not have symptoms of low magnesium. Tell your doctor right away if you have any of these symptoms:</item> </list> <table width="100%"> <col width="50%"/> <col width="50%"/> <tbody> <tr styleCode="Toprule"> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>seizures</item> <item> <caption>•</caption>dizziness</item> <item> <caption>•</caption>abnormal or fast heart beat</item> <item> <caption>•</caption>jitteriness</item> <item> <caption>•</caption>jerking movements or shaking (tremors)</item> </list> </td> <td valign="top"> <list listType="unordered"> <item> <caption> </caption> <list listType="unordered"> <item> <caption>•</caption>muscle weakness</item> <item> <caption>•</caption>spasms of the hands and feet</item> <item> <caption>•</caption>cramps or muscle aches</item> <item> <caption>•</caption>spasm of the voice box</item> </list> </item> </list> </td> </tr> </tbody> </table> <paragraph>Your doctor may check the level of magnesium in your body before you start taking NEXIUM or during treatment if you will be taking NEXIUM for a long period of time.</paragraph> <list listType="ordered"> <item> <caption> </caption>• Stomach growths (fundic gland polyps). People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year.</item> </list> <paragraph>The most common side effects with NEXIUM may include:</paragraph> <table width="100%"> <col width="50%"/> <col width="50%"/> <tbody> <tr styleCode="Toprule"> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>headache</item> <item> <caption>•</caption>diarrhea </item> <item> <caption>•</caption>nausea </item> <item> <caption>•</caption>gas </item> </list> </td> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>abdominal pain</item> <item> <caption>•</caption>constipation</item> <item> <caption>•</caption>dry mouth</item> <item> <caption>•</caption>drowsiness</item> </list> </td> </tr> </tbody> </table> <paragraph>Other side effects:</paragraph> <paragraph> <content styleCode="bold">Serious allergic reactions</content>. Tell your doctor if you get any of the following symptoms with NEXIUM:</paragraph> <table width="100%"> <col width="50%"/> <col width="50%"/> <tbody> <tr styleCode="Toprule"> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>rash</item> <item> <caption>•</caption>face swelling</item> </list> </td> <td valign="top"> <list listType="unordered"> <item> <caption>•</caption>throat tightness</item> <item> <caption>•</caption>difficulty breathing</item> </list> </td> </tr> </tbody> </table> <paragraph>Your doctor may stop NEXIUM if these symptoms happen.</paragraph> <paragraph>Tell your doctor if you have any side effects that bother you or that do not go away. These are not all the possible side effects with NEXIUM. </paragraph> <paragraph>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.</paragraph> <paragraph> <content styleCode="bold">How should I store NEXIUM?</content> </paragraph> <list listType="unordered"> <item> <caption>•</caption>Store NEXIUM at room temperature between 68°F to 77°F (20°C to 25°C).</item> <item> <caption>•</caption>Keep the container of NEXIUM closed tightly.</item> </list> <paragraph> <content styleCode="bold">Keep NEXIUM and all medicines out of the reach of children.</content> </paragraph> <paragraph> <content styleCode="bold">General information about NEXIUM</content> </paragraph> <paragraph>Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use NEXIUM for a condition for which it was not prescribed. Do not give NEXIUM to other people, even if they have the same symptoms you have. It may harm them. </paragraph> <paragraph>This Medication Guide summarizes the most important information about NEXIUM. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about NEXIUM that is written for health professionals. </paragraph> <paragraph>For more information, go to www.purplepill.com or call 1-800-463-9486.</paragraph> <paragraph> <content styleCode="bold">What are the ingredients in NEXIUM?</content> </paragraph> <paragraph>Active ingredient: esomeprazole magnesium trihydrate</paragraph> <paragraph> <content styleCode="bold">Inactive ingredients in NEXIUM Delayed-Release Capsules (including the capsule shells):</content> glyceryl monostearate 40-55, hydroxypropyl cellulose, hypromellose, magnesium stearate, methacrylic acid copolymer type C, polysorbate 80, sugar spheres, talc, triethyl citrate, gelatin, FD&amp;C Blue #1, FD&amp;C Red #40, D&amp;C Red #28, titanium dioxide, shellac, ethyl alcohol, isopropyl alcohol, n-butyl alcohol, propylene glycol, sodium hydroxide, polyvinyl pyrrolidone, and D&amp;C Yellow #10. </paragraph> <paragraph> <content styleCode="bold">Inactive granules in NEXIUM For Delayed-Release Oral Suspension:</content> dextrose, xanthan gum, crospovidone, citric acid, iron oxide, and hydroxypropyl cellulose.</paragraph> <paragraph> <content styleCode="bold">Instructions for Use</content> </paragraph> <paragraph>For instructions on taking Delayed-Release Capsules, see the section of this leaflet called “<content styleCode="bold">How should I take NEXIUM?</content>” </paragraph> <paragraph>Take NEXIUM For Delayed-Release Oral Suspension as follows:</paragraph> <list listType="unordered"> <item> <caption>•</caption>NEXIUM For Delayed-Release Oral Suspension comes in foil packets containing 2.5 mg, 5 mg, 10 mg, 20 mg, or 40 mg strengths.</item> <item> <caption>•</caption>You should use an oral syringe to measure the amount of water needed to mix your dose. Ask your pharmacist for an oral syringe.</item> <item> <caption>•</caption>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a container, then add the contents of a foil packet containing the dose prescribed by your doctor.</item> <item> <caption>•</caption>If your prescribed dose is 10 mg, 20 mg, or 40 mg, add 15 mL of water to a container, then add the contents of a foil packet containing the dose prescribed by your doctor. </item> <item> <caption>•</caption>If you or your child are instructed to use more than one foil packet for the prescribed dose, follow the mixing instructions provided by your pharmacist or doctor. </item> <item> <caption>•</caption>Stir.</item> <item> <caption>•</caption>Leave 2 to 3 minutes to thicken.</item> <item> <caption>•</caption>Stir and take dose within 30 minutes. If not used within 30 minutes, throw away this dose and mix a new dose. </item> <item> <caption>•</caption>If any medicine remains after drinking, add more water, stir, and take dose right away.</item> <item> <caption>•</caption>For young children, you can give the dose with an oral syringe. Rinse the oral syringe with water after each use.</item> </list> <paragraph>NEXIUM Delayed-Release Capsules and NEXIUM For Delayed-Release Oral Suspension may be given through a nasogastric tube (NG tube) or gastric tube, as prescribed by your doctor. Follow the instructions below:</paragraph> <paragraph>NEXIUM Delayed-Release Capsules:</paragraph> <list listType="unordered"> <item> <caption>•</caption>Open the capsule and empty the granules into a 60 mL catheter tipped syringe. Mix with 50 mL of water. Use only a catheter tipped syringe to give NEXIUM through a NG tube.</item> <item> <caption>•</caption>Replace the plunger and shake the syringe well for 15 seconds. Hold the syringe with the tip up and check for granules in the tip.</item> <item> <caption>•</caption>Give the medicine right away.</item> <item> <caption>•</caption>Do not give the granules if they have dissolved or have broken into pieces.</item> <item> <caption>•</caption>Attach the syringe to the NG tube. Give the medicine in the syringe through the NG tube into the stomach. </item> <item> <caption>•</caption>After giving the granules, flush the NG tube with more water.</item> </list> <paragraph>NEXIUM For Delayed-Release Oral Suspension:</paragraph> <list listType="unordered"> <item> <caption>•</caption>NEXIUM For Delayed-Release Oral Suspension comes in foil packets containing 2.5 mg, 5 mg, 10 mg, 20 mg, or 40 mg strengths.</item> <item> <caption>•</caption>Use only a catheter tipped syringe to give NEXIUM through a NG tube or gastric tube.</item> <item> <caption>•</caption>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a catheter tipped syringe, then add the contents of a foil packet containing the dose prescribed by your doctor.</item> <item> <caption>•</caption>If your prescribed dose is 10 mg, 20 mg, or 40 mg, add 15 mL of water to a catheter tipped syringe, then add the contents of a foil packet containing the dose prescribed by your doctor. </item> <item> <caption>•</caption>Shake the syringe right away and then leave it for 2 to 3 minutes to thicken.</item> <item> <caption>•</caption>Shake the syringe and give the medicine through the NG or gastric tube (French size 6 or larger) into the stomach within 30 minutes. </item> <item> <caption>•</caption>Refill the syringe with the same amount of water (either 5 mL or 15 mL of water depending on your dose).</item> <item> <caption>•</caption>Shake the syringe and flush any remaining medicine from the NG tube or gastric tube into the stomach.</item> </list> <paragraph>This Medication Guide has been approved by the U.S. Food and Drug Administration.</paragraph> <paragraph>AstraZeneca Pharmaceuticals LP</paragraph> <paragraph>Wilmington, DE 19850</paragraph> <paragraph>Revised 06/2018</paragraph> <paragraph>NEXIUM is a registered trademark of the AstraZeneca group of companies.</paragraph> <paragraph>©2018 AstraZeneca Pharmaceuticals LP. All rights reserved</paragraph> </text> <effectiveTime value="20180607"/> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_922e528c-fc87-47f7-a4fd-1093b59dc446"> <id root="bd25c789-72bd-4fd7-bc28-8f1ce5aaa959"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 20 mg 30 Capsules</title> <text> <paragraph>NDC 0186-5020-31</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium)</paragraph> <paragraph>30 Delayed-Release </paragraph> <paragraph>Capsules</paragraph> <paragraph>Rx only                     20 mg*</paragraph> <paragraph>Dispense the accompanying </paragraph> <paragraph>Medication Guide to each patient. </paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id1196656412" referencedObject="ID_3a01aa34-718b-49a1-a3af-2a70d7d45af2"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ID_3a01aa34-718b-49a1-a3af-2a70d7d45af2"> <text>Nexium 20 mg 30 count bottle label</text> <value mediaType="image/jpeg"> <reference value="image-06.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_af76d8e7-1379-42c0-abbc-39cdf132f600"> <id root="25ff6732-ce30-4e11-820c-84b1df4969d8"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 40 mg 30 Capsules</title> <text> <paragraph>NDC 0186-5040-31</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium)</paragraph> <paragraph>30 Delayed-Release</paragraph> <paragraph>Capsules</paragraph> <paragraph>Rx only                    40 mg*</paragraph> <paragraph>Dispense the accompanying </paragraph> <paragraph>Medication Guide to each patient. </paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id-796291319" referencedObject="ID_11cf0906-8870-4d61-b5ea-7307ccd37a5a"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ID_11cf0906-8870-4d61-b5ea-7307ccd37a5a"> <text>Nexium 40 mg 30 count bottle label</text> <value mediaType="image/jpeg"> <reference value="image-07.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_104b66e5-dabf-454a-b823-9be94ca2ac90"> <id root="e50c28b9-9033-41ba-8aa1-1e1361037ba7"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 2.5 mg Oral Suspension</title> <text> <paragraph>NDC 0186-4025-01</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium*)</paragraph> <paragraph>2.5 mg</paragraph> <paragraph>For Delayed-Release Oral Suspension</paragraph> <paragraph>Each carton contains 30 Child-resistant packets.</paragraph> <paragraph>*Each packet contains 2.8 mg of esomeprazole magnesium trihydrate </paragraph> <paragraph> which is equivalent to 2.5 mg of esomeprazole as enteric-coated granules.</paragraph> <paragraph>Dispense the enclosed Medication Guide to each patient. </paragraph> <paragraph>30 Single Dose Packets</paragraph> <paragraph>Rx only</paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id425694162" referencedObject="ID_8abc8de9-cf30-4a7c-982d-05a1f15651f0"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ID_8abc8de9-cf30-4a7c-982d-05a1f15651f0"> <text>Nexium 2.5 mg 30 single dose packets</text> <value mediaType="image/jpeg"> <reference value="image-08.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_55719cdb-d448-48de-9f53-c54a8178beaa"> <id root="7680d95e-ced4-403e-8af8-39c9c7d325c3"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 5 mg Oral Suspension</title> <text> <paragraph>NDC 0186-4050-01</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium*)</paragraph> <paragraph>5 mg</paragraph> <paragraph>For Delayed-Release </paragraph> <paragraph>Oral Suspension</paragraph> <paragraph>Each carton contains 30 Child-resistant packets.</paragraph> <paragraph>*Each packet contains 5.6 mg of esomeprazole magnesium trihydrate </paragraph> <paragraph> which is equivalent to 5 mg of esomeprazole as enteric-coated granules.</paragraph> <paragraph>Dispense the enclosed Medication Guide to each patient. </paragraph> <paragraph>Rx only</paragraph> <paragraph>30 Single Dose Packets</paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id1242986923" referencedObject="ID_277f3537-55fe-481f-a100-3c7d01179322"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ID_277f3537-55fe-481f-a100-3c7d01179322"> <text>Nexium 5 mg 30 single dose packets</text> <value mediaType="image/jpeg"> <reference value="image-09.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_c46359bf-5e4a-44ca-b174-660cf26f28c7"> <id root="5a2e58c8-975d-47a7-9241-84ebe12278e9"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 10 mg Oral Suspension</title> <text> <paragraph>NDC 0186-4010-01</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium*)</paragraph> <paragraph>10 mg</paragraph> <paragraph>For Delayed-Release </paragraph> <paragraph>Oral Suspension</paragraph> <paragraph>Each carton contains 30 Child-resistant packets.</paragraph> <paragraph>*Each packet contains 11.1 mg of esomeprazole magnesium trihydrate </paragraph> <paragraph> which is equivalent to 10 mg of esomeprazole as enteric-coated granules.</paragraph> <paragraph>Dispense the enclosed Medication Guide to each patient. </paragraph> <paragraph>Rx only</paragraph> <paragraph>30 Single Dose Packets</paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id-1944679833" referencedObject="ID_79f4c390-9b8a-4b00-9328-529e5e41eeda"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="ID_79f4c390-9b8a-4b00-9328-529e5e41eeda"> <text>Nexium 10 mg 30 single dose packets</text> <value mediaType="image/jpeg"> <reference value="image-10.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_f24653c8-ac6a-424f-81e0-e4b447be7cc3"> <id root="b71c6168-04fa-4f64-8a45-0908f530c049"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>PACKAGE/LABEL PRINCIPAL DISPLAY PANEL – 20 mg Oral Suspension</title> <text> <paragraph>NDC 0186-4020-01</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium*)</paragraph> <paragraph>20 mg</paragraph> <paragraph>For Delayed-Release </paragraph> <paragraph>Oral Suspension</paragraph> <paragraph>Each carton contains 30 Child-resistant packets.</paragraph> <paragraph>*Each packet contains 22.3 mg of esomeprazole magnesium trihydrate </paragraph> <paragraph> which is equivalent to 20 mg of esomeprazole as enteric-coated granules.</paragraph> <paragraph>Dispense the enclosed Medication Guide to each patient. </paragraph> <paragraph>Rx only</paragraph> <paragraph>30 Single Dose Packets</paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id1136831866" referencedObject="BB2CE2E8-8DEA-464F-B5C8-E7615D3415BB"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="BB2CE2E8-8DEA-464F-B5C8-E7615D3415BB"> <text>Nexium 20 mg 30 single dose packets</text> <value mediaType="image/jpeg"> <reference value="image-11.jpg"/> </value> </observationMedia> </component> </section>

<?xml version="1.0" encoding="UTF-8"?><section ID="ID_5b1f0868-8551-4acf-ad3e-84592ad7d518"> <id root="212bd4e7-9c45-48d6-8ef4-4193389698ab"/> <code code="51945-4" codeSystem="2.16.840.1.113883.6.1" displayName="PACKAGE LABEL.PRINCIPAL DISPLAY PANEL"/> <title>Package/Label Display Panel </title> <text> <paragraph>NDC 0186-4040-01</paragraph> <paragraph>NEXIUM^® </paragraph> <paragraph>(esomeprazole magnesium*)</paragraph> <paragraph>40 mg</paragraph> <paragraph>For Delayed-Release Oral Suspension</paragraph> <paragraph>Each carton contains 30 Child-resistant packets.</paragraph> <paragraph>*Each packet contains 44.5 mg of esomeprazole magnesium trihydrate </paragraph> <paragraph> which is equivalent to 40 mg of esomeprazole as enteric-coated granules.</paragraph> <paragraph>Dispense the enclosed Medication Guide to each patient. </paragraph> <paragraph>Rx only</paragraph> <paragraph>30 Single Dose Packets</paragraph> <paragraph>AstraZeneca</paragraph> <renderMultiMedia ID="id1777673442" referencedObject="CEFB2F39-26DF-4348-8BA4-26BBAC1F37A7"/> </text> <effectiveTime value="20180607"/> <component> <observationMedia ID="CEFB2F39-26DF-4348-8BA4-26BBAC1F37A7"> <text>Nexium 40 mg 30 single dose packets</text> <value mediaType="image/jpeg"> <reference value="image-12.jpg"/> </value> </observationMedia> </component> </section>