Nexium 40 mg Dose Twice a Day: When to Take & Side Effects (Dr. farahat).

Our content is not intended nor recommended as a substitute for medical advice by your doctor. Use for informational purposes only.

Your doctor may prescribe Nexium twice-daily dose when conventional daily dosing fails to control GERD or PUD. However, Nexium 40 mg twice a day carries a higher risk of side effects. 

The risk is higher if you are older than the age of 65 years. So, don’t take such a dose without the consultation of your doctor. 

Indications: when to take Nexium 40 mg twice a day?

Esomeprazole (Nexium®) is a proton pump inhibitor (PPI). Your body metabolizes (deactivates) Nexium inside your liver.

People are different when it comes to the rate of Nexium deactivation. If you are a rapid metabolizer, your liver will deactivate Nexium more rapidly.

Some people have gene mutations that lead to rapid metabolism (deactivation) of Nexium. So, the once-daily dose of Nexium becomes less effective.

A twice-daily dose of Nexium can be helpful in such a case. Furthermore, Nexium 40 mg twice-daily dose is more effective than other PPIs in rapid metabolizers (reference).

Indications of Nexium 40 mg twice daily dose:

  • Poorly controlled GERD, peptic ulcer disease, or chronic gastritis on the once-daily 40 mg Nexium.
  • Nighttime gastrointestinal reflux disease (GERD) not responding to the once-daily regimen.
  • Presence of esophageal erosions (seen by endoscopy) that is not responding to the once-daily regimen for 8 weeks.
  • During H. pylori treatment.
  • Some rare diseases may require Nexium 40 mg twice a day as Zollinger-Ellison syndrome. 

Although Nexium is currently an OTC medication. Don’t take Nexium 40 mg without consulting your doctor. Your doctor has to evaluate your eligibility for such dose to:

  • Ensure you get a true benefit from it.
  • Ensure you will not have significant side effects or drug interactions.


 How Long Nexium Takes to Heal GERD, Ulcers, Gastritis, and LPR?

Why you Should Take Pantoprazole First Thing in the Morning: Gastroenterologist Explains.

How to take Nexium 40 mg twice a day?

The best time to take Nexium 40 mg twice-daily regimen is one hour before your breakfast and dinner. The one-hour gap will allow enough time for Nexium to reduce stomach acid before your meals

Don’t take Nexium immediately before or after eating. This timing will reduce its efficacy. Also, you will not feel any improvement.

Try to be around the 12 hours dose interval for the maximum effect of Nexium. Taking the twice-daily dose closely in time (for example, 6 or 8 hours apart) is not recommended. 


  • You can take the capsule as a whole one hour before the meal. Also, you can open the capsule and mix it with one tablespoon of applesauce (reference).
  • Swallow the Nexium/applesauce mix without warming or storage. 
  • Nexium tablets (not capsules) shouldn’t be crushed or chewed.

For how long should you take the twice-daily dose?

Your doctor will determine the period of Nexium twice-daily dosing. The duration is often 4-8 weeks for people with GERD, erosive esophagitis, and barret’s esophagus.

With erosive esophagitis, your doctor may repeat the dose if there is incomplete healing. And this is another 4-8 weeks of Nexium 40 mg twice a day (reference).

After the period of Nexium 40 mg twice daily, your doctor may gradually withdraw it. For example, Nexium 40 mg or 20 once daily for another few weeks.

Safety and side effects of Nexium twice-daily dose?

Nexium is considered a high-risk medication in the elderly (aged more than 65 years).

With the dose increase, the risk of adverse effects also increases. So, ask your doctor before taking Nexium 40 mg twice a day.

Possible side effects include:

  • Headache (the risk of headache increases with increasing the dose). Also, headache is the most common side effect of Nexium.
  • Dizziness, drowsiness, or irritability.
  • Risk of kidney affection. 
  • Itching and pruritis.
  • Abdominal pain, constipation, diarrhea, or flatulence. 
  • Cough.
  • Nausea or vomiting. 
  • Liver affection (hepatitis).
  • Rare side effects such as chest pain, hypertension, acne, thyroid gland affection, and others. Learn more.

What are the alternatives to Nexium 40 mg twice-daily regimen?

Your doctor may decide to use another medication or dose. We, as doctors, think in terms of efficacy versus safety. 

The optimal goal is obtaining maximum efficacy with minimum side effects. 

So, if you didn’t respond to Nexium 40 mg once daily, your doctor may think of another alternative before the twice-daily regimen:

  • Nexium 20 mg twice daily instead of 40 mg once daily in the morning. 
  • Shift to another type of PPI such as Pantoprazole, Rabeprazole. A once-daily regimen for another PPI can be effective without the need for a twice-daily Nexium regimen. Genetic differences between people lead to a variable response to different PPIs.
  • Optimize your diet and lifestyle factors by using a GERD pillow or losing weight.  
  • Extend the period of single-dose Nexium instead of double the dose.