AstraZeneca is pulling its injectable acid suppressant Nexium from Korea, marking its second high-profile product withdrawal in just over a year and deepening fears that multinational drugmakers are scaling back in response to the country’s aggressive drug pricing system.

The company told Korea Biomedical Review in a note Friday that it “will discontinue the supply of Nexium IV from the first half of 2026,” citing a combination of portfolio shifts, local generic competition, and an intent to focus on “the next wave of innovative medicines” for Korean patients. 

The decision, AstraZeneca said, “is not related to the safety, efficacy or quality of Nexium IV.”

The injectable formulation of Nexium, or esomeprazole, is used primarily in emergency and surgical settings to treat bleeding gastric and duodenal ulcers. While the oral tablet will remain available, the injection’s exit is expected to force changes in hospital protocols. 

Generic versions from Chong Kun Dang and Dongkwang Pharm are on the market, but Nexium IV had remained the preferred choice in many institutions due to physician familiarity and its potency, according to hospital specialists.

AstraZeneca’s decision follows its 2024 market exit for Forxiga (dapagliflozin), the company’s blockbuster diabetes drug, after losing pricing protection and facing a deluge of generics. That withdrawal, too, came despite steady use and patient demand.

“When you force a company to keep slashing prices after patent expiration, even if the drug remains widely used, it kills the incentive to stay,” said Professor Jung Hwoon-yong of gastroenterology at Asan Medical Center. “The market is still there. The clinical need is still there. But the return vanishes.”

Jung sees the latest exit as part of a broader shift. “In the past, we were one of the top trial destinations. Now we’re slipping. Companies are moving their studies, and eventually, their drugs, elsewhere,” he said.

Data from the Korea National Enterprise for Clinical Trials (KoNECT) supports that shift. In 2024, Korea’s share of global trials dropped from fourth to sixth, while its participation in multinational trials fell to eleventh place.

“In the past, companies came here because of infrastructure and efficiency,” Jung said. “Now they’re moving studies elsewhere. If we can’t guarantee sustainable pricing, we’ll lose more than just drugs. We’ll lose relevance.”

Not everyone expects Nexium’s exit to cause immediate disruption. “If alternative drugs are available, I don’t think it will pose a major problem,” said Professor Lee Sang-kil of internal medicine at Severance Hospital, in a written response to Korea Biomedical Review. “However, the disappearance of the original drug may still have a slight but nonetheless negative impact that cannot be entirely ruled out.”

At the clinical level, Nexium IV’s departure will likely prompt a switch to pantoprazole, another proton pump inhibitor injection. Still, some physicians are uneasy about losing the original drug.

“Nexium and pantoprazole are not identical in practice,” Jung said. “Pantoprazole is more stable and easier to administer, but Nexium is more potent. Its formulation is finicky. You need to use a separate IV line or it can crystallize. Still, we trusted it.”

That trust, he said, does not automatically transfer to generics. “We haven’t used the Nexium IV generics extensively. We don’t know how stable they are. And without strong data, most hospitals will switch to pantoprazole rather than experiment.”

The concern, he added, is not just the switch but what it signals. “This isn’t just AstraZeneca,” he said. “This is a dilemma for every global pharma company entering Korea.”

A spokesperson for a multinational drugmaker echoed that sentiment in a conversation with Korea Biomedical Review, speaking on condition of anonymity. “Korea isn’t just a low-price market. It sets a reference for other countries. Once your price drops here, it drags everything else down,” the spokesperson said. “And as long as that continues, reimbursement becomes unworkable in multiple markets.”

That pricing pressure is reflected in global comparisons. A 2024 RAND study found that U.S. drug prices are 2.78 times higher than the average across 33 countries, and 4.22 times higher for brand-name therapies. 

Korea consistently ranks near the bottom. A January 2025 analysis found that drugs listed under Korea’s pharmaco-economic exemption system were priced at just 65 percent of global averages.

“Korea slashes prices so deeply that it’s almost impossible to recover development or even production costs,” Jung said. “And once companies pull out, it’s not just a drug that disappears. It’s also the trials, the training, the support systems.”

He pointed to a recent case where a domestic company shuttered its plant for a low-cost bile acid sequestrant, leaving patients with no alternatives. “They had to apply for emergency importation through the Korea Orphan and Essential Drug Center,” he said. “But the drug didn’t work the same. And that’s happening more often than people realize.”

Jung warned that without a shift in pricing policy, Korea risks losing access to future treatments. “Imagine knowing a therapy exists, seeing it approved everywhere else, but never having it reach your country. That’s a kind of torture,” he said.

AstraZeneca, meanwhile, is pivoting to other assets. Its intranasal flu vaccine FluMist received Korean approval in May and is expected to launch this season. At a press briefing in Seoul, the company reiterated its focus on innovative medicines.

“We remain dedicated to saving lives and enhancing the quality of life for Korean patients,” AstraZeneca said in its note. “And we continue to focus on developing and bringing other innovative medicines to Korea.”

Still, Nexium’s withdrawal is likely to ripple beyond the gastroenterology ward. The injection is used across surgery, emergency medicine and critical care. “It’s more widely used than people think,” Jung said. “And once it’s gone, many physicians will be forced to switch to generics they don’t fully trust or to a different drug entirely.”

He likened the situation to a technological mismatch. “It’s like the Imjin War,” he said, referring to the 16th-century conflict where Korean forces, outgunned by Japanese firearms, fought with traditional weapons. “Other countries are using muskets. We’re left with bows.”

And that divide, he argued, is only growing. “We developed endoscopy procedures that outpaced Europe and the U.S.,” he said. “But without the tools or drugs to go with them, we fall behind. Not because of skill, but because of access.”

Lower prices may appeal to policymakers, but Jung believes the system needs balance. “If the price is slashed to the point where companies can’t make even a small profit, that’s not regulation. That’s extraction,” he said. “And at some point, patients will be the ones paying the price.”