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Interactions between Cal-nate and Esomeprazole

1 drug interaction and 7 additional warnings found for the following 2 drugs:

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Drug interactions

Moderate drug interactions

Moderate:

multivitamins, prenatal esomeprazole

Applies to: Cal-nate (multivitamin, prenatal) and esomeprazole
Monitor

Inhibitors of the proton pump (PPIs or potassium-competitive acid blockers [PCABs]) may impair the gastrointestinal absorption of nonheme iron, a process that is dependent on an acidic environment. The interaction was suspected in two patients with iron deficiency anemia due to gastrointestinal blood loss that were unresponsive to oral iron replacement therapy, even after the bleeding had apparently stopped. Both patients had been on omeprazole for six months while being treated with ferrous sulfate. An iron-loading test was performed on one of the patients and indicated iron malabsorption. Within two months after discontinuation of omeprazole, notable improvements in hemoglobin level and mean corpuscular volume (MCV) were observed in both patients, and iron absorption was significantly increased in the patient who underwent absorption testing. In a case review of patients with hereditary hemochromatosis treated at one institution, investigators observed a reduced requirement for maintenance phlebotomy in seven patients following initiation of PPI therapy (mean 2.5 L blood removed/year before PPI therapy vs. 0.5 L/year during PPI therapy), presumably due to reduced tissue iron accumulation stemming from impaired absorption of dietary nonheme iron. Mean annual phlebotomy requirement during PPI therapy in these patients was also lower than that in controls who had never taken a PPI (mean 2.3 L blood removed/year). The same group of investigators also studied iron absorption in 14 patients fed an iron-loaded meal before and after PPI therapy for one week. PPI therapy was associated with a 51% reduction in area under the serum iron concentration-time curve (AUC 0 to 4 hours); a 55% reduction in maximum increase of serum iron following ingestion of iron-loaded meal; and a 46% reduction in percent recovery of administered iron at peak serum iron concentration. Interestingly, the interaction has not been reported in healthy, iron-replete individuals. In a study of 109 patients with Zollinger-Ellison syndrome who had not undergone gastric resection, omeprazole treatment for an average of 5.7 years did not significantly decrease body iron stores or cause iron deficiency compared to H2-receptor antagonist therapy or no gastric acid-suppressant treatment. It is possible that the interaction may not affect people with healthy iron stores because of compensation by dietary heme iron, which typically comprises only a small fraction of dietary iron but whose absorption is not dependent on gastrointestinal pH. In contrast, dietary heme iron alone may not be sufficient to restore normal iron balance in patients with anemia or those with defective regulatory mechanisms of iron absorption.

Management

Patients with iron deficiency may not respond adequately to oral iron replacement therapy during coadministration of PPIs or PCABs. If an interaction is suspected after ruling out other causes, it may be appropriate to discontinue the PPI or PCAB or consider administering iron parenterally.

References (12)
  1. (2022) "Product Information. PriLOSEC (omeprazole)." Merck & Co., Inc
  2. (2001) "Product Information. Prevacid (lansoprazole)." TAP Pharmaceuticals Inc
  3. (2001) "Product Information. Aciphex (rabeprazole)." Janssen Pharmaceuticals
  4. (2001) "Product Information. Protonix (pantoprazole)." Wyeth-Ayerst Laboratories
  5. (2001) "Product Information. Nexium (esomeprazole)." Astra-Zeneca Pharmaceuticals
  6. Sharma VR, Brannon MA, Carloss EA (2004) "Effect of omeprazole on oral iron replacement in patients with iron deficiency anemia." South Med J, 97, p. 887-9
  7. Nand S, Tanvetyanon T (2004) "Proton pump inhibitors and iron deficiency: is the connection real?" South Med J, 97, p. 799
  8. Stewart CA, Termanini B, Sutliff VE, et al. (1998) "Iron absorption in patients with Zollinger-Ellison syndrome treated with long-term gastric acid antisecretory therapy." Aliment Pharmacol Ther, 12, p. 83-98
  9. Hutchison C, Geissler CA, Powell JJ, Bomford A (2007) "Proton pump inhibitors suppress absorption of dietary non-haem iron in hereditary haemochromatosis." Gut, 56, p. 1291-5
  10. (2009) "Product Information. Kapidex (dexlansoprazole)." Takeda Pharmaceuticals America
  11. (2022) "Product Information. Voquezna Dual Pak (amoxicillin-vonoprazan)." Phathom Pharmaceuticals, Inc
  12. (2022) "Product Information. Voquezna Triple Pak (amoxicillin/clarithromycin/vonoprazan)." Phathom Pharmaceuticals, Inc

Food/lifestyle interactions

Moderate food/lifestyle interactions

Moderate:

multivitamins, prenatal Food/Lifestyle

Applies to: Cal-nate (multivitamin, prenatal)
Adjust dosing interval

Concomitant use of some oral medications may reduce the bioavailability of orally administered iron, and vice versa. Food taken in conjunction with oral iron supplements may reduce the bioavailability of the iron. However, in many patients intolerable gastrointestinal side effects occur necessitating administration with food.

Management

Ideally, iron products should be taken on an empty stomach (i.e., at least 1 hour before or 2 hours after meals), but if this is not possible, administer with meals and monitor the patient more closely for a subtherapeutic effect. Some studies suggest administration of iron with ascorbic acid may enhance bioavailability. In addition, administration of oral iron products and some oral medications should be separated whenever the bioavailability of either agent may be decreased. Consult the product labeling for specific separation times and monitor clinical responses as appropriate.

References (2)
  1. "Product Information. Feosol (ferrous sulfate)." SmithKline Beecham
  2. (2021) "Product Information. Accrufer (ferric maltol)." Shield Therapeutics
Moderate:

esomeprazole Food/Lifestyle

Applies to: esomeprazole
Adjust dosing interval

Food may interfere with the absorption of esomeprazole. The manufacturer reports that the area under the concentration-time curve for esomeprazole following a single 40 mg dose was 33% to 53% lower when administered after food intake as opposed to during fasting conditions.

Management

Esomeprazole should be taken at least one hour before meals. When administered to patients receiving continuous enteral nutrition, some experts recommend that the tube feeding should be interrupted for at least 1 hour before and 1 hour after the dose of esomeprazole is given.

References (2)
  1. (2001) "Product Information. Nexium (esomeprazole)." Astra-Zeneca Pharmaceuticals
  2. Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT (2009) "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm, 66, p. 1438-67

Disease interactions

5 potential interactions Applies to: 5 conditions, including Osteoporosis, Diarrhea, Liver Disease, Pseudomembranous Colitis, and Magnesium Imbalance.

Diarrhea

Major:

esomeprazole

Esomeprazole has a major potential interaction with Diarrhea.

Published observational studies suggest that proton pump inhibitor (PPI) use may be associated with an increased risk of Clostridium difficile-associated diarrhea (CDAD), especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve. It is recommended that patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Close monitoring is recommended in patients with diarrhea and in those taking antibacterial agents as CDAD has been reported with the use of nearly all these agents. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

Liver Disease

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Liver Disease.

Esomeprazole is primarily metabolized by the liver. In patients with mild to moderate hepatic impairment (Child Pugh Class A and B), little drug accumulation has been observed following once-daily, multiple-dose administration. No dosage adjustments are necessary in these patients. In severe hepatic impairment (Child Pugh Class C), however, substantial increases in plasma drug concentrations have been demonstrated. The manufacturer recommends a maximum dosage of 20 mg once daily in patients with severe liver disease.

Magnesium Imbalance

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Magnesium Imbalance.

Symptomatic and asymptomatic hypomagnesemia has been reported rarely in patients treated with PPIs for at least 3 months, in most cases after a year of therapy. Serious adverse events can include tetany, seizures, and arrhythmias. Caution should be used in patients prone to magnesium imbalances such as patients taking other medications that can cause hypomagnesemia (e.g., diuretics). Regular monitoring is recommended.

Osteoporosis

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Osteoporosis.

Various published observational studies have reported that PPI therapy may be associated with an increased risk for osteoporosis related fractures of the hip, wrist or spine. The risk was increased in patients who received high doses (multiple daily doses), and long term treatment (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Caution should be used in patients at risk for osteoporosis related fractures and should be managed according to established treatment guidelines.

Pseudomembranous Colitis

Major:

esomeprazole

Esomeprazole has a major potential interaction with Pseudomembranous Colitis.

Published observational studies suggest that proton pump inhibitor (PPI) use may be associated with an increased risk of Clostridium difficile-associated diarrhea (CDAD), especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve. It is recommended that patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Close monitoring is recommended in patients with diarrhea and in those taking antibacterial agents as CDAD has been reported with the use of nearly all these agents. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

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More resources

Cal-nate

A total of 172 drugs are known to interact with Cal-nate.

esomeprazole

A total of 236 drugs are known to interact with esomeprazole.

Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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