Proton pump inhibitors – esomeprazole

Last updated on October 7, 2022

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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 OR 2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST	Indefinite
3. For eradication of Helicobacter pylori, as part of triple therapy	Maximum 14 days

Special Authority criteria

Approval period

1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer

2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST

Indefinite

3. For eradication of Helicobacter pylori, as part of triple therapy

Maximum 14 days

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Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium

Practitioner exemptions

None

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

Special Authority request form(s)

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Proton pump inhibitors – esomeprazole

Practitioner exemptions

Special notes

Special Authority request form(s)