Ava-Omeprazole Product Monograph

ACTIONS AND CLINICAL PHARMACOLOGY

Omeprazole inhibits the gastric enzyme H⁺, K⁺ -ATPase (the proton pump) which catalyzes the exchange of H⁺ and K⁺. It is effective in the inhibition of both basal acid secretion and stimulated acid secretion. The inhibition is dose-dependent. Daily oral doses of omeprazole 20 mg and higher showed a consistent and effective acid control. A mean reduction of 24-hour intragastric acidity of approximately 80% was achieved during repeated dosing of 20 mg daily.

Treatment with omeprazole alone has been shown to suppress, but not eradicate Helicobacter pylori (H. pylori), a bacterium that is strongly associated with acid peptic disease. Approximately 90 to 100% of patients with duodenal ulcers, and 80% of patients with gastric ulcers, are infected with H. pylori. Clinical evidence indicates a synergistic effect between omeprazole and certain antibiotics in achieving eradication of H. pylori. Eradication of H. pylori is associated with symptom relief, healing of mucosal lesions, decreased rate of duodenal ulcer recurrence and long-term remission of peptic ulcer disease, reducing the need for prolonged antisecretory therapy.

There is no statistically significant change in the bioavailability (AUC, C_max) of amoxicillin during concomitant treatment with omeprazole in healthy volunteers.

There is an increase in the bioavailability (AUC) and half-life of omeprazole, and bioavailability (AUC) and C_max of clarithromycin, during concomitant administration in healthy volunteers.

There is no statistically significant change in the bioavailability (AUC, C_max) of metronidazole during concomitant treatment with omeprazole in healthy volunteers.

Omeprazole is absorbed rapidly. After an initial oral dose of Omeprazole, approximately 35% of the drug is absorbed from the gastrointestinal tract. Following one week of therapy, the percentage absorbed is 43. Neither food nor antacids have any effect on the bioavailability. Peak plasma levels occur within about four hours.

The terminal plasma half–life is about 40 minutes. The antisecretory effect of omeprazole is directly proportional to the AUC; it is not dependent on the plasma concentration at any given time. Omeprazole is 95% bound to plasma proteins.

Omeprazole undergoes first-pass metabolism by the cytochrome P-450 system, mainly in the liver, through CYP 2C19 and CYP 3A4. The CYP 2C19 isozyme, which is involved in the metabolism of all available proton pump inhibitors, exhibits polymorphism. Approximately 3% of the Caucasian population and 15-20% of Asian populations lack a functional CYP 2C19 enzyme and are called poor metabolisers.

Following i.v. and oral administration, 80% of the dose is recovered as urinary metabolites; the remaining 20% is excreted in the feces.

Comparative Bioavailability

Two comparative bioavailability studies were performed using healthy human volunteers – one under fasting conditions and one with food. The rate and extent of absorption of omeprazole following a single 40 mg (2 x 20 mg capsules) oral dose of AVA-OMEPRAZOLE and LOSEC were measured and compared. The results from measured data are summarized as follows:

Table 1

Table 2

Two additional comparative bioavailability studies were performed using healthy human volunteers – one under fasting conditions and one with food. The rate and extent of absorption of omeprazole following a single 40 mg (2 x 20 mg capsules) oral dose of AVA-OMEPRAZOLE and PRILOSEC were measured and compared. The results from measured data are summarized as follows:

Table 3

Table 4

INDICATIONS AND CLINICAL USE

AVA-OMEPRAZOLE (omeprazole) is indicated in the treatment of conditions where a reduction of gastric acid secretion is required, such as:

• duodenal ulcer;
• gastric ulcer;
• NSAID-associated gastric and duodenal ulcers;
• reflux esophagitis;
• symptomatic gastroesophageal reflux disease (GERD), i.e., heartburn and regurgitation;
• Zollinger-Ellison Syndrome (pathological hypersecretory condition);
• Eradication of Helicobacter pylori (H. pylori)

AVA-OMEPRAZOLE, in combination with clarithromycin and either amoxicillin or metronidazole, is indicated for the treatment of patients with peptic ulcer disease associated with Helicobacter pylori infection. The optimal timing for eradication therapy in patients whose ulcer is not clinically active (i.e., asymptomatic) remains to be determined.

Patients who fail to have their infection eradicated may be considered to have H. pylori resistant to the antimicrobials used in the eradication regimen. Therefore, therapy involving alternative effective antimicrobial agents should be considered (if re-treating).

It has been demonstrated that resistance to metronidazole is a negative predictive factor, decreasing the eradication rate of H. pylori obtained with triple therapy (omeprazole,

metronidazole and clarithromycin) by 10-20%. The addition of omeprazole to metronidazole and clarithromycin appears to reduce the effect of primary resistance and the development of secondary resistance compared to antimicrobials alone.

Table 5: Results of studies in patients with a history of duodenal ulcer who were H. pylori -positive.

*500 mg metronidazole appears to be equivalent to 400 mg with regards to efficacy and safety. Study 1: Patients included in the APT and PP analyses were assessed for H. pylori status by UBT pre- and post-treatment, n = 684 (APT analysis).

Study 2: Patients included in the ITT and PP analyses were assessed for H. pylori status by UBT and culture pre and post-treatment, n = 514 (ITT analysis).

Table 6: Results of studies in patients with active peptic ulcer who were H. pylori positive (ITT analysis).

*500 mg metronidazole appears to be equivalent to 400 mg with regards to efficacy and safety.

Study 3: Patients with duodenal ulcer, included in the ITT analysis, were assessed for H. pylori status by UBT and histology pre- and post-treatment, n = 146 (ITT analysis).

Study 4: Patients with gastric ulcer, included in the ITT analysis, were assessed for H. pylori status by UBT and histology pre- and post-treatment, n = 145 (ITT analysis).

CONTRAINDICATIONS

Hypersensitivity to omeprazole, substituted benzimidazoles, or any of the components of this medication (see PHARMACEUTICAL INFORMATION).

WARNINGS

When gastric ulcer is suspected, the possibility of malignancy should be excluded before therapy with omeprazole is instituted, as treatment with omeprazole may alleviate symptoms and delay diagnosis.

Concomitant administration with atazanavir, nelfinavir or clopidogrel is not recommended (see PRECAUTIONS, Drug Interactions).

Use in Pregnancy

The safety of omeprazole in pregnancy has not been established. AVA-OMEPRAZOLE should not be administered to pregnant women unless the expected benefits outweigh the potential risks.

Nursing Mothers

It is not known if omeprazole is secreted in human milk. AVA-OMEPRAZOLE should not be given to nursing mothers unless its use is considered essential.

Use in Children

The safety and effectiveness of omeprazole in children has not yet been established.

PRECAUTIONS

General

Pseudomembranous colitis has been reported with nearly all antibacterial agents, including clarithromycin and amoxicillin, and may range in severity from mild to life threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents.

Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of Clostridia. Studies indicate that a toxin produced by Clostridium difficile is a primary cause of “antibiotic-associated colitis”.

After the diagnosis of pseudomembranous colitis has been established, therapeutic measures should be initiated. Mild cases of pseudomembranous colitis usually respond to discontinuation of the drug alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation, and treatment with an antibacterial drug clinically effective against Clostridium difficile colitis.

Decreased gastric acidity due to any means, including any proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to a slightly increased risk of gastrointestinal infections such as Salmonella, Campylobacter and possibly Clostridium difficile.

Use in the Elderly

Elderly subjects showed increased bioavailability (36%), reduced total plasma clearance (to 250 mL/min) and prolonged (50%) elimination half-life (to 1.0 hour). The daily dose in elderly patients should, as a rule, not exceed 20 mg (see DOSAGE AND ADMINISTRATION).

Patients with Hepatic Insufficiency

Patients with impaired liver function showed a 75% increase in bioavailability, reduced total plasma clearance (to 67 mL/min), and a four-fold prolongation of the elimination half-life (to 2.8 hours). Twenty mg given once daily to these patients for four weeks was well tolerated, with no accumulation of omeprazole or its metabolites. The daily dose in patients with severe liver disease should, as a rule, not exceed 20 mg (see DOSAGE AND ADMINISTRATION).

Patients with Renal Insufficiency

The disposition of intact omeprazole is unchanged in patients with impaired renal function, and no dose adjustment is needed in these patients (see DOSAGE AND ADMINISTRATION).

Carcinogenicity

The rat carcinogenicity study (24 months) revealed a gradual development from gastric ECL-cell hyperplasia to carcinoids at the end of their normal life span during administration with 14-140 mg/kg/day of omeprazole. No metastasis developed. No carcinoids developed during 18 months’ high dose treatment of mice (14-140 mg/kg/day). Similarly, administration of omeprazole up to 28 mg/kg/day in dogs for seven years did not cause any carcinoids.

The gastric carcinoids in rats were related to sustained hypergastrinemia secondary to acid inhibition and not to omeprazole per se (see TOXICOLOGY). Similar observations have been made after administration of histamine H₂-receptor blockers and also in partially fundectomized rats.

Short- and long-term treatment in a limited number of patients for up to six years has not resulted in any significant pathological changes in gastric oxyntic endocrine cells.

Drug Interactions

The absorption of some drugs might be altered due to decreased intragastric acidity. Thus, it can be predicted that the absorption of ketoconazole and itraconazole will decrease during omeprazole treatment, as it does during treatment with other acid secretion inhibitors or antacids.

Omeprazole is metabolized by the cytochrome P-450 system (CYP), mainly in the liver. The pharmacokinetics of the following drugs which are also metabolized through the cytochrome P-450 system have been evaluated during concomitant use of omeprazole in humans: aminopyrine, antipyrine, clopidogrel, diazepam, phenytoin, warfarin (or other vitamin K antagonists), cilostazol*, theophylline, voriconazole, digoxin, propranolol, metoprolol, lidocaine, quinidine, ethanol, piroxicam, diclofenac and naproxen.

*not marketed in Canada.

Omeprazole inhibits CYP 2C19, the major omeprazole metabolizing enzyme, and is partially metabolized by CYP 3A4. Drugs known to inhibit CYP 2C19 or CYP 3A4 or both (such as clarythromycin and voriconazole) may lead to increased omeprazole serum levels by decreasing the rate of omeprazole’s metabolism. Drugs known to induce CYP 2C19 or CYP 3A4 or both (such as rifampin and St John’s Wort) may lead to decreased omeprazole serum levels by increasing omeprazole’s rate of metabolism.

Aminopyrine and Antipyrine

After 14 days’ administration of 60 mg omeprazole once daily, the clearance of aminopyrine was reduced by 19%; the clearance of antipyrine was reduced by 14%. After 14 days’ administration of 30 mg once daily, no significant changes in clearance were noted.

Clopidogrel

Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Co-administration of clopidogrel with omeprazole, an inhibitor of CYP2C19, reduces the pharmacological activity of clopidogrel given concomitantly or 12 hours apart. Concomitant use of drugs that inhibit the activity of this enzyme may result in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition.

In a crossover clinical study, 72 healthy subjects were administered clopidogrel (300-mg loading dose followed by 75 mg/day) alone and with omeprazole (80 mg at the same time as clopidogrel) for 5 days. The exposure to the active metabolite of clopidogrel was decreased by 46% (Day 1) and 42% (Day 5) when clopidogrel and omeprazole were administered together. Mean inhibition of platelet aggregation (IPA) was diminished by 47% (24 hours) and 30% (Day

1. 5) when clopidogrel and omeprazole were administered together. In another study 72 healthy subjects were given the same doses of clopidogrel and omeprazole but the drugs were administered 12 hours apart; the results were similar indicating that administering clopidogrel and omeprazole at different times does not prevent their interaction.

The pharmacological interaction between clopidogrel and omeprazole is related to partly shared metabolic pathways. Whether such an interaction translates into negative clinical outcomes is uncertain.

Diazepam, Phenytoin, Warfarin (or other vitamin K antagonists) and Cilostazol*

As omeprazole is metabolized through cytochrome P-450 2C19, it can alter the metabolism and prolong elimination of diazepam, warfarin (R-warfarin), phenytoin and cilostazol*.

*not marketed in Canada.

Diazepam

Following repeated dosing with omeprazole 40 mg once daily, the clearance of diazepam was decreased by 54%. The corresponding decrease after omeprazole 20 mg was 26%.

Warfarin (or other vitamin K antagonists)

Concomitant administration of omeprazole 20 mg in healthy subjects had no effect on plasma concentrations of the (S)-enantiomer of warfarin, but caused a slight, though statistically significant increase (12%) in the less potent (R)-enantiomer concentrations. A small but statistically significant increase (11%) in the anticoagulant effect of warfarin was also seen. In patients receiving warfarin or other vitamin K antagonists, monitoring of INR (International Normalised Ratio) is recommended and a reduction of the warfarin (or other vitamin K antagonist) dose may be necessary. Concomitant treatment with omeprazole 20 mg daily did not change coagulation time in patients on continuous treatment with warfarin.

Phenytoin

Following three weeks’ treatment with omeprazole 20 mg once daily, the steady state plasma levels of phenytoin in epileptic patients already receiving concomitant phenytoin treatment were not significantly affected. Urinary excretion of phenytoin and its main metabolite were also unchanged.

After single intravenous and oral doses of omeprazole 40 mg in young, healthy volunteers, the clearance of phenytoin was decreased by 15-20%, and half-life was prolonged by 20-30%. Following repeated dosing with omeprazole 40 mg once daily, the elimination half-life of phenytoin was increased by 27%. Thus, there appears to be a dose dependent inhibition of elimination of phenytoin by omeprazole.

Patients receiving phenytoin and warfarin (or other vitamin K antagonists) should be monitored to determine if it is necessary to adjust the dosage of these drugs when taken concomitantly with omeprazole. Results from a range of interaction studies with omeprazole versus other drugs indicate that omeprazole, 20-40 mg given repeatedly, has no influence on any other clinically relevant isoforms of CYP, as shown by the lack of metabolic interaction with substrates for CYP 1A2 (caffeine, phenacetin, theophylline), CYP 2C9 (S-warfarin), CYP 2D6 (metoprolol, propranolol), CYP 2E1 (ethanol), and CYP 3A (cyclosporine, lidocaine, quinidine, estradiol).

Cilostazol*

Omeprazole, given in doses of 40 mg to health subjects in a cross-over study, increased C_max and AUC for cilostazol by 18% and 26% respectively, and one of its active metabolites, 3,4-dihydrocilostazol, by 29% and 69% respectively.

*not marketed in Canada

Antiretroviral Drugs

Omeprazole, like other acid-reducing agents, has been reported to interact with some antiretroviral drugs. The clinical importance and the mechanisms behind these interactions are not always known. A change in gastric pH may change the absorption of the antiretroviral drug. Other possible interaction mechanisms are via CYP 2C19.

Reports indicate that omeprazole has a significant impact on atazanavir exposure, decreasing AUC, C_max and C_min. This interaction is only partially overcome by the addition of ritonavir to the atazanavir treatment regimen. Similarly, decreased serum levels of nelfinavir have also been reported when given together with omeprazole. Concomitant administration of omeprazole with atazanavir and nelfinavir is therefore not recommended. For other antiretroviral drugs, such as saquinavir, elevated serum levels have been reported. There are also some antiretroviral drugs where unchanged serum levels have been reported when given with omeprazole (See WARNINGS).

Tacrolimus

Although no clinical studies have been undertaken, there is a possibility that the concomitant administration of omeprazole and tacrolimus may increase serum levels of tacrolimus.

Theophylline

No effects on oral or I.V. theophylline kinetics have been observed after repeated once daily doses of 40 mg omeprazole.

Voriconazole

Concomitant administration of omeprazole and a CYP 2C19 and CYP 3A4 inhibitor, voriconazole, resulted in more than doubling of the omeprazole exposure. However, a dose adjustment of omeprazole is not required.

Digoxin

The absorption of digoxin can increase during treatment with omeprazole and other drugs that reduce gastric acidity. Concomitant treatment with omeprazole (20 mg daily) and digoxin in ten healthy subjects increased the bioavailability of digoxin by an average of 10% (up to 30% in two out of ten subjects).

Propranolol and Metoprolol

No effects on propranolol kinetics were observed in a steady-state trial with 20 mg of omeprazole daily. Similarly, no effects on steady-state plasma levels of metoprolol were observed after concomitant treatment with 40 mg omeprazole daily.

Lidocaine

No interaction with a single intravenous dose of lidocaine or its active metabolite, MEGX, was

found after one week of pre-treatment with omeprazole 40 mg once daily. There were no interactions between omeprazole and lidocaine or MEGX concerning pharmacokinetic variables.

Quinidine

After one week of omeprazole 40 mg once daily, no effect was observed on the kinetics or pharmacodynamics of quinidine.

Ethanol

There was no significant effect on the pharmacokinetics of ethanol after omeprazole 20 mg.

Piroxicam, Diclofenac and Naproxen

There was no significant effect on the steady state pharmacokinetics of piroxicam, diclofenac and naproxen following repeated dosing with omeprazole 20 mg in healthy volunteers.

Antacids

No interaction with concomitantly administered antacids has been found.

Food

No interaction with food has been found.

Laboratory Tests

During treatment with antisecretory drugs serum gastrin increases in response to the decreased acid secretion. Also chromogranin A (CgA) increases due to decreased gastric acidity. The increased CgA level may interfere with investigations for neuroendocrine tumours. To avoid this interference omeprazole treatment should be temporarily stopped five days before CgA measurements.

Other Interactions

As demonstrated with other PPIs, prolonged use may impair the absorption of protein-bound Vitamin B₁₂ and may contribute to the development of Vitamin B₁₂ deficiency.

ADVERSE REACTIONS

Omeprazole is well tolerated. Most adverse reactions have been mild and transient and there has been no consistent relationship with the treatment. Adverse events have been recorded during controlled clinical investigations in 2764 patients exposed to omeprazole or reported from routine use. In a controlled clinical trial comparing omeprazole to placebo, the prevalence of adverse events with omeprazole 40 mg once daily was similar to the placebo group. In short-term, comparative, double-blind studies with histamine H₂-receptor antagonists, there was no significant difference in the prevalence of adverse events between omeprazole and the H₂-receptor antagonists. An extensive evaluation of laboratory variables has not revealed any

significant changes during omeprazole treatment which are considered to be clinically important.

The following adverse events (at a rate of more than one percent) have been reported in individuals receiving omeprazole therapy in controlled clinical situations: diarrhea (2.8%); headache (2.6%); flatulence (2.3%); abdominal pain (1.7%); constipation (1.3%); and dizziness/vertigo (1.1%).

The following is a list of adverse events reported in clinical trials or reported from routine use. Events are classified within body system categories. The following definitions of frequencies are used: common: ≥ 1/100; uncommon: ≥ 1/1000 and <1/100; rare: <1/1000 and very rare: <1/10000.

Central and Peripheral Nervous System: Common: headache. Uncommon: dizziness, paraesthesia, somnolence, insomnia and vertigo. Rare: reversible mental confusion, agitation, aggression, depression and hallucinations, predominantly in severely ill patients.

Endocrine: Rare: gynaecomastia.

Gastrointestinal: Common: diarrhoea, constipation, abdominal pain, nausea/vomiting and flatulence. Rare: dry mouth, stomatitis and gastrointestinal candidiasis.

Hematological: Rare: leukopenia, thrombocytopenia, agranulocytosis and pancytopenia.

Hepatic: Uncommon: increased liver enzyme levels. Rare: encephalopathy in patients with pre-existing severe liver disease; hepatitis with or without jaundice and hepatic failure.

Musculoskeletal: Rare: arthralgia, muscular weakness and myalgia.

Skin: Uncommon: rash, dermatitis and/or pruritus, and urticaria. Rare: photosensitivity, erythema multiforme, Stevens-Johnsons syndrome, toxic epidermal necrolysis (TEN) and alopecia.

Other Adverse Events: Uncommon: malaise, hypersensitive reactions including urticaria. Rare: hypersensitive reactions including angioedema, fever, bronchospasm, interstitial nephritis and anaphylactic shock; increased sweating, peripheral edema, blurred vision, taste disturbances and hyponatraemia. Very rare: hypomagnesaemia.

H. pylori Eradication Combination Therapy: The following adverse events (at a rate of more than 1%) were recorded during controlled clinical trials in 493 patients receiving omeprazole, amoxicillin and clarithromycin: diarrhea (28%), taste disturbances (15%), headache (5%), flatulence (4%), nausea (3%), abdominal pain (2%), ALT increased (1%), epigastric pain (1%), pharyngitis (1%) and glossitis (1%).

The following adverse events (at a rate of more than 1%) were recorded during controlled clinical trials in 494 patients receiving omeprazole, metronidazole and clarithromycin: taste disturbances (14%), diarrhea (13%), headache (6%), ALT increased (6%), flatulence (5%), nausea (5%), AST increased (5%), dyspepsia (3%), dry mouth (2%), dizziness/vertigo (2%), epigastric pain (1%), pharyngitis (1%), eructation (1%) and fatigue (1%).

SYMPTOMS AND TREATMENT OF OVERDOSAGE

No information is available on the effects of higher doses in man, and specific recommendations for treatment cannot be given. Single oral doses of up to 400 mg omeprazole have not resulted in any severe symptoms, and no specific treatment has been needed. As in all cases where overdosing is suspected, treatment should be supportive and symptomatic. Any unabsorbed material should be removed from the gastrointestinal tract, and the patient should be carefully monitored.

The oral LD₅₀ of omeprazole in male and female rats and mice was greater than 4000 mg/kg. In dogs, the only sign of acute toxicity was vomiting which occurred at doses of approximately 600 mg/kg (see TOXICOLOGY).

When used in combination with antibiotics, the Prescribing Information/Product Monograph for those antibiotics should be consulted.

DOSAGE AND ADMINISTRATION

Capsules should be swallowed whole. DO NOT open, divide, crush or chew the capsules.

Duodenal Ulcer

Acute Therapy: The recommended adult oral dose is 20 mg given once daily. Healing usually occurs within two weeks. For patients not healed after this initial course of therapy, an additional two weeks of treatment is recommended.

Refractory Patients: In patients with duodenal ulcer refractory to other treatment regimens, the recommended adult doses are 20 mg or 40 mg given once daily. Healing is usually achieved within four weeks in such patients.

Maintenance Therapy for Duodenal Ulcer: Over 95% of duodenal ulcer patients are H. pylori- positive, and should be treated with eradication therapy, as described below. A small percentage of patients who are H. pylori-negative will experience a disease recurrence and will require maintenance treatment with an antisecretory agent. The recommended omeprazole dose is 10 mg once daily, increased to 20-40 mg once daily, as necessary.

Gastric Ulcer

Acute Therapy: The recommended adult dose is 20 mg given once daily. Healing usually occurs within four weeks. For patients not healed after this initial course of therapy, an additional four weeks of treatment is recommended.

Refractory Patients: In patients with gastric ulcer refractory to other treatment regimens, the recommended dose is 40 mg given once daily. Healing is usually achieved within eight weeks. For management of suspected drug overdose, contact your regional Poison Control Centre immediately.

Maintenance Therapy for Gastric Ulcer: About 80% of gastric ulcer patients are H. pylori-positive, and should be treated with eradication therapy, as described below. A small percentage of patients who are H. pylori-negative will experience a disease recurrence and will require maintenance treatment with an antisecretory agent. The recommended omeprazole dose is 20 mg once daily, increased to 40 mg once daily, as necessary.

NSAID-Associated Gastric or Duodenal Ulcers

The issue of whether or not eradication of H. pylori in patients with NSAID-associated ulcers might have beneficial preventive effects has not yet been settled.

Acute Therapy: In patients with NSAID-associated gastric or duodenal ulcers, the recommended adult dose is 20 mg given once daily. Symptom resolution is rapid and healing usually occurs within four weeks. For those patients not healed after this initial course of therapy, an additional four weeks of treatment is recommended.

Maintenance Therapy: For the prevention of relapse in patients with NSAID-associated gastric or duodenal ulcers, the recommended adult dose is 20 mg given once daily, for up to six months.

Helicobacter pylori-Associated Peptic Ulcer Disease

Omeprazole, Amoxicillin and Clarithromycin Triple Therapy: The recommended dose for eradication of H. pylori is AVA-OMEPRAZOLE 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg, all twice daily for seven days.

Omeprazole, Metronidazole and Clarithromycin Triple Therapy: The recommended dose for eradication of H. pylori is AVA-OMEPRAZOLE 20 mg, metronidazole 500 mg and clarithromycin 250 mg, all twice daily for seven days.

To ensure healing and/or symptom control, further treatment with 20 mg AVA-OMEPRAZOLE once daily for up to three weeks is recommended for patients with active duodenal ulcer, and with 20-40 mg AVA-OMEPRAZOLE once daily for up to 12 weeks for patients with active gastric ulcer.

Patient compliance with treatment regimens for the eradication of H. pylori has been demonstrated to have a positive effect on eradication outcome. In clinical trials, patients treated with triple-therapy regimens have shown high compliance rates.

Susceptibility testing (MIC values derived from the Agar dilution method) of H. pylori to metronidazole and clarithromycin is available for 486 primary isolates from patients with a history of duodenal ulcer in one European study.

Resistance to metronidazole (MIC >8 mg/L) was detected in 131 strains (27%), while nine strains (2%) were resistant to clarithromycin (MIC >1 mg/L). Secondary resistance to metronidazole developed in strains from four patients treated with

omeprazole/metronidazole/clarithromyin. Similarly, in those patients treated with

omeprazole/metronidazole/clarithromycin or omeprazole/amoxicillin/clarithromycin combinations, secondary resistance to clarithromycin developed in strains from four patients. For amoxicillin, the MIC values at pre- or post-therapy did not indicate any primary, or the development of secondary, resistance of H. pylori.

Reflux Esophagitis

Acute Therapy: The recommended adult dose is 20 mg given once daily. In most patients, healing occurs within four weeks. For patients not healed after this initial course of therapy, an additional four weeks of treatment is recommended.

Refractory Patients: For patients with reflux esophagitis refractory to other treatment regimens, the recommended dose is 40 mg given once daily. Healing is usually achieved within eight weeks.

Maintenance Therapy for Reflux Esophagitis: For the long-term management of patients with healed reflux esophagitis, 10 mg omeprazole once daily has been found to be effective in controlled clinical trials of 12 months’ duration, and in continuous maintenance treatment in a limited number of patients for a period of up to six years. In the case of recurrence, the dose can be increased to 20-40 mg omeprazole.

Symptomatic Gastroesophageal Reflux Disease (i.e., Heartburn and Regurgitation)

The recommended adult dose is 20 mg given once daily. Symptom relief should be rapid. If symptom control is not achieved after 4 weeks, further investigation is recommended. Since some patients respond adequately to 10 mg given once daily, individual dose adjustment should be considered. For the maintenance of symptom relief in patients with gastroesophageal reflux disease (i.e., heartburn and regurgitation), the recommended adult dose is 10 mg given once daily.

Zollinger-Ellison Syndrome

The dose of AVA-OMEPRAZOLE used in the treatment of Zollinger-Ellison Syndrome will vary with the individual patient.

The recommended initial dose is 60 mg, given once daily. More than 90% of the patients with the severe form of the disease and inadequate response to other therapies have been adequately controlled with doses of 20 mg to 120 mg daily. With doses greater than 80 mg, the dose should be divided and given twice daily. Doses should be adjusted to the individual patient’s need and should continue as long as clinically indicated. Doses up to 120 mg three times daily have been administered.

Patients with Renal Insufficiency: No dose adjustment is required (see PRECAUTIONS).

Patients with Hepatic Insufficiency: No dose adjustment is required. The daily dose should not exceed 20 mg (see PRECAUTIONS).

Elderly Patients: No dose adjustment is required. The daily dose should not exceed 20 mg (see PRECAUTIONS).

The capsules should be swallowed whole with sufficient water.

PHARMACEUTICAL INFORMATION

AVA-OMEPRAZOLE 20 mg capsules contain 20 mg/capsule of omeprazole.

In addition to omeprazole, each capsule contains the non-medicinal ingredients mannitol, povidone, magnesium hydroxide, triethyl citrate and eudragit. The capsule shell contains the non-medicinal ingredients gelatin, red iron oxide and titanium dioxide.

Stability and Storage Recommendations

Store bottle tightly capped at room temperature 15 - 30°C. Protect from moisture.

AVAILABILITY OF DOSAGE FORMS

AVA-OMEPRAZOLE 20 mg capsules are two-piece hard gelatin capsules with an opaque pink body and an opaque reddish-brown cap, imprinted “APO 020”. Available in bottles of 100 and 500.