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# Pantoprazole ## Overview Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion. ## 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 on chronic NSAID therapy. * Pathological hypersecretory conditions, including Zollinger-Ellison syndrome. ## Adult Dosing * **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks. * **Maintenance of healing of erosive esophagitis:** 40 mg orally once daily. * **NSAID-associated gastric ulcers:** 40 mg orally once daily, usually for up to 8 weeks. * **Zollinger-Ellison syndrome:** Dosing is individualized. Usual starting dose is 40 mg orally twice daily. Doses up to 240 mg IV daily (given as 40 mg every 6 hours) or 240 mg PO daily (divided doses) have been used. ## Pediatric Dosing * **GERD/erosive esophagitis (1 month to 5 years):** 1.1 to 2.2 mg/kg orally once daily. Maximum dose: 20 mg daily. * **GERD/erosive esophagitis (5 to 12 years):** 20 mg orally once daily. For more severe cases, 40 mg orally once daily may be used. * **GERD/erosive esophagitis (12 years and older):** 40 mg orally once daily. Dosing for pediatric IV administration is less established and should be guided by institutional protocols. ## Dose Adjustments No dose adjustment is typically necessary for patients with hepatic impairment, though maximum doses should be considered. No dose adjustment is needed for renal impairment. ## Contraindications * Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation. ## Adverse Effects * **Common:** Headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, flatulence. * **Serious:** Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency, lupus erythematosus (cutaneous and systemic). ## Key Drug Interactions * **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, iron salts, mycophenolate mofetil, posaconazole. Coadministration may decrease absorption. * **Methotrexate:** PPIs may increase methotrexate levels. Consider interruption of pantoprazole if high-dose methotrexate is used. * **CYP2C19 substrates:** Pantoprazole may inhibit CYP2C19. Caution with drugs like clopidogrel, though clinical significance is debated. ## Monitoring * Electrolytes (magnesium, sodium, potassium) with prolonged therapy or in patients on concomitant diuretics. * Vitamin B12 levels with prolonged therapy (typically >3 years). * Bone mineral density in patients at risk for osteoporosis. * Stool for C. difficile if diarrhea develops. ## Clinical Pearls * Pantoprazole is available in oral and IV formulations. * Oral pantoprazole is generally taken 30-60 minutes before a meal. * IV pantoprazole should be given as a slow infusion over at least 15 minutes. * Long-term use of PPIs is associated with increased risk of C. difficile infection, bone fractures, and hypomagnesemia. * Discontinuation should be tapered if feasible to minimize rebound acid hypersecretion. *** *This information is intended for healthcare professionals. Please consult the most current prescribing information and relevant literature for complete details, including contraindications, warnings, precautions, drug interactions, and adverse reactions, as well as to confirm dosing based on specific patient factors and institutional guidelines.*