What Should You Not Take with Nexium?

Globally, nearly one-quarter of adults use a proton pump inhibitor (PPI) like Nexium [1.10.1]. Before taking it, it's crucial to understand what you should not take with Nexium to avoid potentially harmful drug interactions.

Quick Summary

Nexium (esomeprazole) can interact with various drugs, affecting their efficacy or increasing risks. Key interactions include blood thinners, certain HIV medications, methotrexate, and St. John's Wort. Always consult a healthcare provider.

Key Points

• Blood Thinners: Do not take Nexium with clopidogrel (Plavix) as it reduces its effectiveness; use with warfarin requires close monitoring due to increased bleeding risk [1.4.3, 1.6.1].

• HIV Medications: Nexium is contraindicated with certain HIV drugs like rilpivirine and atazanavir because it severely reduces their absorption and effectiveness [1.2.3, 1.11.3].

• Methotrexate: Taking Nexium with high-dose methotrexate can lead to toxic levels of the cancer drug in the body [1.5.1].

• Absorption Issues: Nexium reduces stomach acid, which can hinder the body's ability to absorb drugs like certain antifungals (ketoconazole) and iron supplements [1.3.2].

• Liver Enzyme Effects: Nexium can block the CYP2C19 enzyme, increasing blood levels of drugs like the antidepressant citalopram [1.7.1, 1.7.2].

• Herbal and OTC Drugs: Avoid taking St. John's Wort or rifampin with Nexium, as they can make it significantly less effective [1.9.1].

• Consult a Professional: Always provide your doctor and pharmacist with a complete list of your medications and supplements to prevent harmful interactions [1.2.1].

Nexium, the brand name for the drug esomeprazole, is a popular proton pump inhibitor (PPI) used to treat conditions like gastroesophageal reflux disease (GERD), stomach ulcers, and Zollinger-Ellison syndrome [1.10.1]. It works by significantly reducing the amount of acid produced in the stomach. While effective, this change in stomach acidity and the way the drug is processed by the liver can lead to significant interactions with other medications.

Why Drug Interactions with Nexium Occur

Nexium's primary actions—reducing gastric acid and being metabolized by the CYP2C19 liver enzyme—are the main reasons for its drug interactions [1.6.3, 1.7.2].

• Reduced Stomach Acid: Many drugs require an acidic environment to be absorbed properly by the body. By lowering stomach acid, Nexium can decrease the absorption and therefore the effectiveness of these medications [1.6.2].
• Liver Enzyme Inhibition: Nexium is metabolized by enzymes in the liver, primarily CYP2C19 [1.6.3]. It can also inhibit this enzyme, which is responsible for breaking down many other drugs. This inhibition can lead to dangerously high levels of other medications in the bloodstream [1.7.2]. Conversely, drugs that induce this enzyme can decrease Nexium's effectiveness [1.9.1].

Major Drug Interactions: What You Should Not Take with Nexium

It is vital to inform your doctor of all prescription drugs, over-the-counter medicines, and supplements you are taking [1.2.1]. Certain interactions can be severe.

Blood Thinners: Clopidogrel and Warfarin

Combining Nexium with the antiplatelet drug clopidogrel (Plavix) should be avoided [1.3.2]. Nexium can reduce clopidogrel's effectiveness in preventing heart attack or stroke [1.4.3]. The FDA has warned against this combination [1.4.2]. For patients taking warfarin, another blood thinner, taking it with Nexium may increase the risk of bleeding. Close monitoring of blood clotting times (INR) is essential if these drugs must be used together [1.6.1, 1.6.3].

Certain HIV Medications

Nexium should not be taken with certain antiretroviral drugs used to treat HIV, such as rilpivirine (Edurant), atazanavir, and nelfinavir [1.2.3, 1.3.2]. By reducing stomach acid, Nexium significantly lowers the absorption of these medications, which can lead to a loss of virologic response and potential drug resistance [1.11.3].

Methotrexate

When taken with high-dose methotrexate (a drug used for cancer and autoimmune diseases), Nexium can dangerously increase and prolong methotrexate levels in the blood [1.5.1]. This interaction raises the risk of methotrexate toxicity. A temporary withdrawal of the PPI is often considered in these cases [1.5.2].

Other Prescription Medications

• Antidepressants: Nexium can increase the blood levels of antidepressants like citalopram (Celexa) and escitalopram (Lexapro), raising the risk of side effects, including serious heart rhythm issues [1.7.1, 1.7.2].
• Digoxin: Taking this heart medication with Nexium can lead to elevated digoxin levels and potential toxicity [1.2.1, 1.3.3].
• Antifungals: The absorption of certain antifungal drugs, such as ketoconazole and itraconazole, may be reduced, making them less effective [1.3.2].
• Tacrolimus: An immunosuppressant, its levels can be increased by Nexium [1.3.2].

Herbal Supplements and Over-the-Counter Drugs

Concomitant use of Nexium with St. John's Wort or the antibiotic rifampin should be avoided. These substances can significantly decrease the concentration of esomeprazole in the body, making the medication less effective [1.2.1, 1.9.1].

Comparison Table: Nexium (Esomeprazole) vs. Prilosec (Omeprazole) Interactions

Nexium and Prilosec are chemically very similar and have many of the same interactions [1.11.3]. Some studies suggest Nexium may have a stronger acid-lowering effect, but one is not generally recommended over the other [1.11.1, 1.11.2]. Both interact with clopidogrel, warfarin, methotrexate, and certain HIV drugs [1.4.2, 1.11.3].

Drug Category	Interacting Drug	Nexium (Esomeprazole) Interaction	Prilosec (Omeprazole) Interaction	Management Advice
Antiplatelet	Clopidogrel	Reduces clopidogrel efficacy. Avoid combination [1.4.3].	Reduces clopidogrel efficacy. Avoid combination [1.4.2].	Use alternative PPI like pantoprazole or an H2 blocker [1.4.2, 1.4.4].
Anticoagulant	Warfarin	May increase warfarin levels and bleeding risk [1.6.1].	May increase warfarin levels and bleeding risk [1.7.4].	Frequent INR monitoring is required [1.6.3].
HIV Antivirals	Rilpivirine, Atazanavir	Reduces antiviral absorption. Contraindicated [1.2.3].	Reduces antiviral absorption. Contraindicated [1.11.3].	Avoid concurrent use. Consult HIV specialist [1.7.4].
Chemotherapy	Methotrexate (high-dose)	Increases methotrexate toxicity risk [1.5.1].	Increases methotrexate toxicity risk [1.7.4].	Temporarily stop PPI during treatment [1.5.2].
Antidepressant	Citalopram	Increases citalopram levels and risk of heart issues [1.7.1].	Increases citalopram levels and risk of heart issues [1.7.2].	Dose adjustment or alternative PPI may be needed [1.7.1].
Herbal	St. John's Wort	Decreases Nexium efficacy. Avoid use [1.9.1].	Decreases Prilosec efficacy. Avoid use [1.9.4].	Do not use together [1.9.3].

Conclusion

The key to safely taking Nexium is open communication with your healthcare provider. Because of its mechanism of action, Nexium can interact with a wide range of medications, from life-saving heart and HIV drugs to common antidepressants and herbal supplements. Always ensure your doctor and pharmacist have a complete list of everything you take to screen for potential interactions and prevent negative health outcomes.

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Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional before making any decisions about your health or medications.

Mayo Clinic - Esomeprazole

Frequently Asked Questions

What is the most serious drug interaction with Nexium?

Among the most serious interactions is with clopidogrel (Plavix), as Nexium can reduce its ability to prevent heart attacks or strokes [1.4.3]. Interactions with high-dose methotrexate and certain HIV medications like rilpivirine are also considered very serious [1.5.1, 1.3.2].

Can I take vitamins with Nexium?

Generally, multivitamins can be taken with Nexium, but long-term use of Nexium can reduce the absorption of vitamin B12 and other minerals like iron [1.2.2]. It is best to consult your healthcare provider about supplementation.

What happens if I take clopidogrel (Plavix) with Nexium?

Taking Nexium with clopidogrel may reduce the anti-clotting activity of clopidogrel, decreasing its effectiveness in preventing a heart attack or stroke [1.4.3]. This combination should be avoided [1.4.2].

How long after taking Nexium can I take other medications?

The timing depends on the specific medication. For drugs whose absorption is affected by stomach acid, spacing the doses may not be effective [1.4.2]. Always follow the advice of your doctor or pharmacist regarding the timing of your medications.

Is it safe to take Tylenol (acetaminophen) with Nexium?

Yes, based on interaction checkers, there is no known direct interaction between Tylenol (acetaminophen) and Nexium [1.2.4]. However, always consult your healthcare provider before combining any medications.

Can I drink alcohol while taking Nexium?

While moderate alcohol consumption is generally not contraindicated with esomeprazole, chronic alcohol use may increase the risk of gastrointestinal bleeding [1.6.3]. Additionally, alcohol can worsen acid reflux symptoms [1.12.2].

Should I avoid certain foods when taking Nexium?

Nexium itself doesn't require specific food restrictions. However, to manage the underlying condition (like GERD), you should avoid foods that trigger acid reflux, such as fried or fatty foods, spicy foods, citrus, chocolate, and coffee [1.12.2].