Proton Pump Inhibitors – Esomeprazole
|
Generic Name |
esomeprazole |
|
Strength |
20 mg, 40 mg |
| Form | tablet |
|
Special Authority Criteria |
Approval Period |
| 1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer. | Indefinite |
| OR | |
| 2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST. | Indefinite |
| OR | |
| 3. For eradication of Helicobacter pylori, as part of triple therapy. | Maximum 14 days |
| PLUS | |
| Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium. | |
Practitioner Exemptions
- No practitioner exemptions.
Special Notes
- CREST is an acronym for the five main features of the limited form of scleroderma: Calcinosis, Raynaud’s disease, Esophageal dysmotility, Sclerodactyly, and Telangiectasia.
- A reasonable trial of rabeprazole and pantoprazole magnesium is considered a trial at usual adult doses for at least 4 weeks each of rabeprazole and pantoprazole magnesium.
