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## Pantoprazole
### Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases acid production in the stomach.
### Primary Indications
* Gastroesophageal reflux disease (GERD) symptomatic treatment and healing of erosive esophagitis.
* Healing of duodenal ulcers.
* H. pylori eradication (in combination with antibiotics).
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome).
### Adult Dosing
* **GERD/Erosive Esophagitis:** 40 mg orally once daily for 4-8 weeks.
* **Duodenal Ulcers:** 40 mg orally once daily for 15-30 days.
* **H. pylori Eradication:** 40 mg orally twice daily for 7 days in combination with amoxicillin and clarithromycin.
* **Pathological Hypersecretory Conditions:** Starting dose typically 40 mg orally twice daily, may be increased as needed. Doses up to 240 mg daily have been used.
### Pediatric Dosing
* **GERD/Erosive Esophagitis:**
* **1 month to <5 years:** 10-20 mg orally once daily. Dosing depends on weight and severity.
* **5 years to <12 years:** 20 mg orally once daily for 4 weeks.
* **12 years and older:** 40 mg orally once daily for up to 8 weeks.
* **Note:** Pediatric dosing may vary based on local protocols and specific clinical guidelines.
### Dose Adjustments
* **Hepatic Impairment:** Maximum dose is typically 20 mg orally once daily for patients with severe hepatic impairment.
### Contraindications
* Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation.
### Adverse Effects
* Common: Headache, diarrhea, nausea, abdominal pain, dizziness.
* Long-term use: Increased risk of C. difficile infection, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency.
### Key Drug Interactions
* **Clopidogrel:** May decrease the antiplatelet effect of clopidogrel. Consider alternative PPIs or monitor closely.
* **Methotrexate:** May increase serum levels of methotrexate.
* **Certain Antiretrovirals (e.g., rilpivirine, atazanavir):** Reduced absorption due to increased gastric pH.
* **Ketoconazole, Itraconazole, Posaconazole:** Reduced absorption due to increased gastric pH.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19 and can affect the metabolism of drugs like citalopram or clopidogrel.
### Monitoring
* Electrolytes (magnesium, sodium, potassium) with prolonged therapy or in patients at risk.
* Bone mineral density with long-term use.
* Clinical symptoms of GERD or ulcer healing.
* Renal function if severe hepatic impairment is present and dose adjustment is made.
### Clinical Pearls
* Administer 30 minutes to 1 hour before a meal.
* Oral suspension: Do not crush or chew. Mix with applesauce or yogurt if needed.
* IV formulation is available for patients unable to take oral medication.
* Long-term PPI use should be reserved for specific indications and periodically reassessed for necessity.
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*This information is intended for healthcare professionals and should not replace consulting the most current prescribing information or local institutional guidelines.*
