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## Pantoprazole
### Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
### Primary Indications
* Erosive esophagitis associated with gastroesophageal reflux disease (GERD)
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
* Healing of duodenal ulcers
* Maintenance of healing of erosive esophagitis
### Adult Dosing
* **Erosive esophagitis, duodenal ulcers:** 40 mg orally or intravenously once daily.
* **Pathological hypersecretory conditions:** Starting dose 40 mg orally or intravenously twice daily, may be increased as needed. Maximum daily dose: 240 mg.
* **Maintenance of healing of erosive esophagitis:** 20 mg orally once daily. Some patients may require 40 mg once daily.
* Dosing duration for erosive esophagitis is typically up to 8 weeks. For duodenal ulcers, up to 4 weeks.
### Pediatric Dosing
* **Erosive esophagitis (ages 5 to 16 years):** 20 mg orally once daily for up to 4 weeks.
* **Erosive esophagitis (ages 1 month to 5 years):** Dosing is based on weight:
* 5 kg to < 10 kg: 5 mg orally once daily.
* 10 kg to < 20 kg: 10 mg orally once daily.
* ≥ 20 kg: 20 mg orally once daily.
* Duration up to 8 weeks.
* **Note:** Pediatric dosing may vary based on local protocols and specific clinical guidelines.
### Dose Adjustments
* **Hepatic impairment:** Maximum daily dose of 40 mg orally once daily.
* **Renal impairment:** No dose adjustment is generally required.
### Contraindications
* Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation.
### Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence.
* **Serious:** *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with prolonged use, hypomagnesemia, vitamin B12 deficiency, fundic gland polyps.
### Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Antiretrovirals (e.g., rilpivirine), antifungals (e.g., ketoconazole, itraconazole), certain tyrosine kinase inhibitors (e.g., erlotinib). May decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Monitor for increased levels of drugs metabolized by this enzyme (e.g., clopidogrel, citalopram, warfarin).
### Monitoring
* Monitor for signs and symptoms of *C. difficile*-associated diarrhea.
* Consider monitoring magnesium levels, especially with prolonged therapy (>1 year) or concomitant use of other magnesium-depleting drugs (e.g., diuretics).
* Assess for bone fracture risk with long-term use.
* Monitor vitamin B12 levels with prolonged therapy.
### Clinical Pearls
* Pantoprazole is available in delayed-release oral formulations and as an intravenous solution.
* Intravenous administration should be completed over at least 2 minutes.
* IV infusion: Slowly infuse 40 mg over 15 minutes.
* For prolonged therapy, especially in elderly patients or those with other risk factors, consider the potential for long-term adverse effects.
* The risk of bone fractures increases with duration of therapy and cumulative dose.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for definitive guidance. Dosing can vary based on individual patient factors and local protocols.*
