Instigar contains the active substance dexlansoprazole, which is a proton pump inhibitor (PPI). PPIs reduce the amount of acid that your stomach makes.

Instigar is used in adults and adolescents aged 12 years and above for the following:

• Treatment of erosive reflux oesophagitis (inflammation with damage to the lining of the oesophagus (food pipe))
• Maintenance of healed erosive reflux oesophagitis and maintenance of relief of heartburn
• Short-term treatment of heartburn and acid regurgitation associated with symptomatic non-erosive gastro-oesophageal reflux disease (GORD). GORD is a condition where stomach acid leaks out of the stomach and comes up into the oesophagus (acid reflux).

By reducing the amount of stomach acid Instigar can heal the damage of the oesophagus and relieve symptoms that can happen with the above conditions and stop them from coming back.

Do not take Instigar

• If you are allergic to dexlansoprazole or any of the other ingredients of this medicine (listed in section 6).

Warnings and precautions
Talk to your doctor before taking or while you are taking Instigar:

• If you have liver problems. Your doctor may have to adjust your dosage.
• If you have stomach problems. Your doctor may perform an additional investigation called an endoscopy (where a very small camera is inserted down your oesophagus to look into your stomach), which can help to exclude more serious causes of your symptoms.
• If you take a proton pump inhibitor like Instigar, especially over a period of more than one year, may slightly increase your risk of fracture in the hip, wrist or spine. Tell your doctor if you have osteoporosis (reduced bone density) or if your doctor has told you that you are at risk of getting osteoporosis (for example, if you are taking steroids).
• If you take Instigar on a long-term basis (longer than 1 year). Your doctor will probably ask to see you regularly so he can check how well you are doing. Tell your doctor if you notice any new symptoms or if any of your symptoms are getting worse.
• If you take other medicines such as digoxin (for the treatment of heart problems) or diuretics (‘water tablets’). Your doctor will probably monitor the magnesium levels in your blood periodically.
• If you have low vitamin B₁₂ levels or have risk factors for low vitamin B₁₂ levels and receive long-term treatment with Instigar. As with all acid reducing agents, Instigar may lead to a reduced absorption of vitamin B₁₂.
• If you have ever had a skin reaction after treatment with a medicine similar to Instigar that reduces stomach acid.
•  If you get a rash on your skin, especially in areas exposed to the sun tell your doctor as soon as you can, as you may need to stop your treatment with Instigar. Remember to also mention any other ill-effects like pain in your joints.
• When taking dexlansoprazole, inflammation in your kidney may occur. Signs and symptoms may include decreased volume of urine or blood in your urine and/or hypersensitivity reactions such as fever, rash, and joint stiffness. You should report such signs to the treating physician.
• Dexlansoprazole can cause rare but severe skin reactions that may affect any part of your body (see also section 4). These serious skin reactions may need to be treated in a hospital and may be life threatening; Skin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet). You may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes. Stop taking Instigar and call your doctor right away. These symptoms may be the first sign of a severe skin reaction.
• If you are due to have a specific blood test (Chromogranin A).

Children
Do not give this medicine to children under 12 years.

Other medicines and Instigar
Tell your doctor if you are taking, have recently taken or might take any other medicines. This is because dexlansoprazole can affect the way some other medicines work. Also, some medicines can affect the way dexlansoprazole works.

Check with your doctor before taking Instigar if you are taking any of the following medicines:

• HIV protease inhibitors such as atazanavir and nelfinavir (to treat HIV)
• Ketoconazole, itraconazole, rifampicin (to treat infections)
• Erlotinib (to treat cancer)
• Digoxin (to treat heart problems)
• Tacrolimus (to prevent transplant rejection)
• Fluvoxamine (to treat depression and other psychiatric diseases)
• Warfarin (to prevent thrombosis)
• Antacids (to treat heartburn or acid regurgitation)
• Sucralfate (for healing ulcers)
• St John’s wort (Hypericum perforatum) (to treat mild depression)
• Methotrexate (to treat cancer)

Pregnancy and breast-feeding
If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor for advice before taking this medicine.

Driving and using machines
Side effects such as dizziness, vertigo, tiredness and visual disturbances sometimes occur in patients taking dexlansoprazole. If you experience side effects like these, you should take caution as your ability to react may be decreased.

You alone are responsible to decide if you are in a fit condition to drive a motor vehicle or perform other tasks that demand increased concentration. Because of their effects or undesirable effects, one of the factors that can reduce your ability to do these things safely is your use of medicines.

Descriptions of these effects can be found in other sections.

Read all the information in this leaflet for guidance.

Discuss with your doctor if you are unsure about anything.

Instigar contains sucrose
Instigar contains sucrose. Each modified-release hard capsule of Instigar 30 mg and 60 mg Modified-release Hard Capsules contains 68 mg or 76 mg sucrose; respectively. If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicinal product.

Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

Swallow the capsules whole with a glass of water. You can take the capsules with or without food. If you have trouble swallowing Instigar capsules whole, you can open the capsules and sprinkle the contents on a tablespoon of apple purée (such as apple sauce). Be sure to swallow the apple mixture right away. Do not chew the mixture. Do not store for later use.

The recommended dose for adults is as follows:

• Treatment of erosive reflux oesophagitis: take 60 mg once daily for 4 weeks. Your doctor may prescribe an additional 4 weeks.
• Maintenance of healed erosive reflux oesophagitis and maintenance of relief of heartburn in patients where prolonged acid suppression is needed: take 30 mg once daily for up to 6 months.
• Treatment of heartburn and acid regurgitation associated with symptomatic non-erosive gastro-oesophageal reflux disease (GORD): take 30 mg once daily for up to 4 weeks.

The recommended dose for adolescents aged 12 to 17 years is as follows:

• Treatment of erosive reflux oesophagitis: take 60 mg once daily for 4 weeks. Your doctor may prescribe an additional 4 weeks.
• Maintenance of healed erosive reflux oesophagitis and maintenance of relief of heartburn in patients where prolonged acid suppression is needed: take 30 mg once daily. Your doctor will define total treatment time.
• Treatment of heartburn and acid regurgitation associated with symptomatic non-erosive gastro-oesophageal reflux disease (GORD): take 30 mg once daily for up to 4 weeks.

Elderly and patients with liver problems: Your doctor may prescribe a lower dose.

Your doctor will advise you how long to take Instigar.

If necessary, your doctor may tell you to take a different dose.

If you take more Instigar than you should
If you accidentally take multiple capsules (overdose), or if someone else takes multiple doses of your medicine at the same time, talk to a doctor immediately.

The following symptoms have been reported in patients who had taken large doses of dexlansoprazole:

• High blood pressure, hot flushes, bruises, throat pain and weight loss.

If you forget to take Instigar
If you forget to take a dose, take it as soon as you remember unless it is nearly time for your next dose. If this happens, skip the missed dose and carry on with your next dose as normal. Do not take a double dose to make up for a forgotten dose.

If you stop taking Instigar
Do not stop treatment early because you feel better. Your condition may not have been fully resolved and may return if you do not finish your course of treatment. Talk to your doctor before stopping this treatment.

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

Like all medicines, this medicine can cause side effects, although not everybody gets them.

In clinical studies side effects associated with dexlansoprazole treatment were mostly mild or moderate.

If you get any of the following side effects, stop taking these capsules and tell your doctor immediately, or contact the casualty department at your nearest hospital:

• Hypersensitivity or serious allergic reactions (frequency not known) such as rash, face swelling, throat tightness, difficulty breathing
• Anaphylactic shock or serious, severe and sudden allergic reaction (frequency not known) with symptoms such as shortness of breath, confusion, pale colour, severe skin eruptions, throat tightness, weakness, gasping for air and unconsciousness.

The most frequently reported side effects (common – may affect up to 1 in 10 people) were:

• Diarrhoea, abdominal pain, headache, feeling sick (nausea), abdominal discomfort, gas (flatulence), constipation and benign polyps in the stomach.

Some patients experienced the following other side effects with dexlansoprazole:
Uncommon (may affect up to 1 in 100 people):

• Difficulty in sleeping
• Depression
• Dizziness
• Altered taste
• High blood pressure
• Hot flushes
• Cough
• Vomiting
• Dry mouth
• Liver function test abnormalities
• Hives
• Itching
• Rash
• Feeling of weakness
• Appetite changes
• Fracture of hip, wrist or spine

Rare (may affect up to 1 in 1,000 people):

• Hallucinations involving the hearing of voices or sounds
• Convulsion
• Tingling or numbness
• Visual disturbance
• Feeling of dizziness or “spinning”
• Yeast infections

 Not known (frequency cannot be estimated from the available data):

• Reduced number of red blood cells. This may cause paleness, weakness, intolerance to physical activity, dizziness, tiredness and confusion
• Bruising or bleeding caused by abnormally low platelet count of unknown cause
• Severe skin reactions (Stevens-Johnson syndrome), toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (DRESS), erythema multiforme, and subacute cutaneous lupus erythematosus. You may also have joint pain or flu-like symptoms, a fever, swollen glands (e.g. in the armpit) and blood tests may show changes in certain white blood cells or liver enzymes
• Blurred vision
• Deafness
• Hepatitis caused by medicines (with symptoms such as loss of appetite, headache, nausea, fatigue, fever, jaundice, pale or clay-coloured stools, dark urine)
• Rash, possibly with pain in the joints
• If you are on dexlansoprazole for more than three months, it is possible that the levels of magnesium in your blood may fall. Low levels of magnesium can be seen as fatigue, involuntary muscle contractions, disorientation, convulsions, dizziness, increased heart rate. If you get any of these symptoms, please tell your doctor promptly. Low levels of magnesium can lead to a reduction in potassium or calcium levels in the blood. Your doctor may decide to perform regular blood tests to monitor your levels of magnesium.
• Low levels of sodium in the blood. Common symptoms include nausea and vomiting, headache, drowsiness and fatigue, confusion, muscle weakness or spasms, irritability, seizures, coma.
• Kidney problems
• Visual hallucinations.

Keep this medicine out of the sight and reach of children.

Store below 30°C.

Store in the original package.

Do not use this medicine after the expiry date which is stated on the package after “EXP”. The expiry date refers to the last day of that month.

Do not use this medicine if you notice any visible signs of deterioration.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.