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Pantoprazole ## Overview Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion by inhibiting the H+/K+-ATPase enzyme system in gastric parietal cells. ## Primary Indications * Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD). * Maintenance of healing of erosive esophagitis. * Treatment of pathological hypersecretory conditions, including Zollinger-Ellison syndrome. ## Adult Dosing * **Erosive Esophagitis Healing:** 40 mg orally or intravenously once daily for up to 8 weeks. * **Erosive Esophagitis Maintenance:** 40 mg orally once daily. Lower doses (e.g., 20 mg) may be sufficient for some patients. * **Pathological Hypersecretory Conditions:** 40 mg orally or intravenously twice daily. Doses may be increased as needed. Usual maximum dose is 240 mg daily. ## Pediatric Dosing Dosing varies by indication and age. Consult specific pediatric guidelines or prescribing information. * **12 to 15 years (Erosive Esophagitis):** 40 mg orally once daily for up to 8 weeks. * **5 to 15 years (Erosive Esophagitis):** 20-40 mg orally once daily. * **Infants and Children < 5 years:** Limited data; use with caution and under specialist guidance. ## Dose Adjustments No dose adjustment is typically required for hepatic or renal impairment, though caution is advised in severe hepatic impairment. ## Contraindications * Known hypersensitivity to pantoprazole or any of its components. * Use of rilpivirine-containing products. ## Adverse Effects Common: Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence. Serious: Clostridium difficile-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency, lupus erythematosus (cutaneous and systemic). ## Key Drug Interactions * **Drugs Dependent on Gastric pH:** Pantoprazole can decrease absorption of drugs requiring acidic environments (e.g., ketoconazole, itraconazole, certain antiretrovirals like rilpivirine). * **Methotrexate:** PPIs may increase methotrexate levels. * **CYP2C19 Substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs metabolized by this enzyme (e.g., clopidogrel - though clinical significance is debated, citalopram, sertraline). ## Monitoring * Monitor for signs and symptoms of Clostridium difficile infection. * Consider serum magnesium levels, especially with prolonged use (≥ 1 year) or concomitant diuretic use. * Assess for bone fracture risk with long-term therapy. * Monitor for symptoms of B12 deficiency with prolonged use. ## Clinical Pearls * Administer pantoprazole 30 minutes before a meal. * Delayed-release tablets can be taken with or without food. * Enteric-coated granules for oral suspension can be mixed with applesauce or apple juice. Do not crush or chew the granules. * Intravenous formulation is available for patients unable to take oral medication. * Long-term use of PPIs is associated with increased risk of fractures, hypomagnesemia, and vitamin B12 deficiency; reassess need for therapy periodically. *** *Disclaimer: This information is intended for clinical use and does not replace professional medical judgment. Always consult the most current prescribing information and relevant literature for complete details and to verify dose recommendations before initiating therapy.*