Esomeprazole

How it works

It irreversibly inhibits the gastric H+/K+-ATPase (proton pump) in parietal cells, profoundly reducing both basal and stimulated gastric acid secretion.

Prescribing in practice

• Treatment may mask the symptoms of gastric cancer, so investigate alarm features such as unintended weight loss, dysphagia, vomiting or gastrointestinal bleeding before and during therapy.
• It inhibits CYP2C19 and can reduce the activation of clopidogrel; long-term use is associated with hypomagnesaemia, increased fracture risk, rebound acid hypersecretion on withdrawal and Clostridioides difficile infection.
• Use the lowest effective course; consider the risk of subacute cutaneous lupus erythematosus and assess the need for continued long-term therapy periodically.

Monitoring

Consider checking serum magnesium before and during prolonged therapy or with interacting drugs, and reassess the ongoing need for treatment at review.

Counselling the patient

• Take the dose before food, swallowing the capsule or tablet whole.
• Report persistent or new symptoms such as difficulty swallowing or unexplained weight loss.
• Do not stop long-term treatment abruptly without advice as symptoms may rebound.

Evidence & guidelines

Proton pump inhibitor efficacy in acid-related disease is supported by extensive randomised trial evidence and reflected in NICE guidance.