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## Pantoprazole
### Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production.
### Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Reduction of risk of NSAID-associated gastric ulcers in patients at risk.
* Pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
### Adult Dosing
* **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks.
* **Maintenance of Healing:** 40 mg orally once daily.
* **NSAID-Associated Ulcers:** 40 mg orally once daily.
* **Pathological Hypersecretory Conditions (e.g., Zollinger-Ellison Syndrome):** Starting dose is typically 40 mg orally twice daily. Doses may be increased as needed. Doses may exceed 160 mg daily; doses >80 mg daily should be divided.
* **Intravenous:**
* **Erosive Esophagitis:** 40 mg IV once daily for up to 7 days.
* **Pathological Hypersecretory Conditions:** 40 mg IV twice daily. Doses may be increased as needed. Doses may exceed 160 mg daily; doses >80 mg daily should be divided.
### Pediatric Dosing
* **Erosive Esophagitis (GERD-associated):**
* **1 to <5 years:** 10 mg orally once daily for up to 8 weeks.
* **5 to <12 years:** 20 mg orally once daily for up to 8 weeks.
* **12 to 17 years:** 40 mg orally once daily for up to 8 weeks.
* **Note:** Pediatric IV dosing is not established. Dosing in children for indications other than erosive esophagitis may vary and is often based on clinical judgment and local protocols.
### Dose Adjustments
* **Hepatic Impairment:** Maximum dose of 20 mg orally once daily. Not recommended for IV use in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment typically required.
### Contraindications
* Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation.
### Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, hypomagnesemia (especially with prolonged use >1 year), fundic gland polyps. Systemic lupus erythematosus. Vitamin B12 deficiency.
### Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** Ketoconazole, itraconazole, posaconazole, iron salts, vitamin B12. Separate administration by at least 2 hours.
* **Methotrexate:** PPIs may increase methotrexate levels. Consider dose interruption.
* **CYP2C19 substrates:** Omeprazole, clopidogrel. Use with caution.
### Monitoring
* Monitor for signs and symptoms of *C. difficile* infection.
* Monitor serum magnesium levels periodically, especially with prolonged therapy (>1 year) or concomitant diuretic use.
* Monitor bone mineral density in patients at risk for osteoporosis.
* Consider monitoring Vitamin B12 levels with long-term therapy.
### Clinical Pearls
* Pantoprazole is available in delayed-release oral formulations and as a powder for injection.
* IV formulation is typically used when oral administration is not possible or for short-term treatment.
* Long-term PPI use is associated with increased risk of fractures, hypomagnesemia, and *C. difficile* infection. Use the lowest effective dose for the shortest duration necessary.
* Consider acid-reducing agents other than PPIs for chronic management if appropriate.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions. Individual patient factors may necessitate deviations from standard recommendations.
