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# Pantoprazole ## Overview Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production. ## Primary Indications * Gastroesophageal reflux disease (GERD) * Healing of erosive esophagitis * Reduction of risk of NSAID-induced gastric ulcers in patients at risk * Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome) ## Adult Dosing * **GERD/Erosive Esophagitis:** 40 mg orally once daily. For severe cases, may increase to 40 mg twice daily. Duration of treatment varies. * **NSAID-induced Ulcer Prophylaxis:** 40 mg orally once daily. * **Pathological Hypersecretory Conditions:** Initiate at 40 mg orally twice daily, may titrate up to 80 mg orally twice daily or more as needed. Maximum recommended dose is 160 mg daily. Intravenous (IV) dosing: * **GERD/Healing of Erosive Esophagitis:** 40 mg IV once daily. * **Pathological Hypersecretory Conditions:** Initiate at 80 mg IV over 15 minutes every 8 hours, may increase to 80 mg IV every 6 hours if needed. Maximum recommended dose is 160 mg daily. ## Pediatric Dosing * **GERD (12 years and older):** 40 mg orally once daily. * **Erosive Esophagitis (5 years and older):** 40 mg orally once daily. For moderate to severe cases, 20 mg orally once daily for patients weighing <40 kg, and 40 mg orally once daily for patients weighing ≥40 kg. **Note:** Pediatric IV dosing is not well established and may depend on local protocols. ## Dose Adjustments No dose adjustment is generally needed for renal impairment. For hepatic impairment, reduce the dose to 20 mg orally once daily. ## Contraindications * Known hypersensitivity to pantoprazole, other benzimidazoles, or any component of the formulation. ## Adverse Effects * **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence. * **Serious:** Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia (can be severe and may lead to hypocalcemia and hypokalemia), vitamin B12 deficiency. ## Key Drug Interactions * **Clopidogrel:** Pantoprazole may decrease the efficacy of clopidogrel. Consider alternative PPIs or avoid concurrent use if possible. * **Drugs Dependent on Gastric pH for Absorption:** Ketoconazole, itraconazole, posaconazole, iron salts, mycophenolate mofetil. Pantoprazole may decrease absorption. * **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. ## Monitoring * Monitor for symptoms of hypomagnesemia (e.g., muscle spasms, tremor, seizures) if used long-term. * Monitor for bone mineral density if risk factors for osteoporosis exist. * Monitor for signs and symptoms of C. difficile infection. * Consider vitamin B12 levels with prolonged use. ## Clinical Pearls * Pantoprazole is available as oral tablets and granules, and IV formulation. * Oral administration: Swallow whole, do not chew or crush. The 40 mg delayed-release granules can be mixed with applesauce or apple juice. * IV administration: Reconstitute and dilute as per manufacturer instructions. Infuse over at least 15 minutes (or longer for higher doses). * Long-term use of PPIs is associated with increased risk of fractures, C. difficile infection, and hypomagnesemia. Use the lowest effective dose for the shortest duration necessary. *** *This information is intended for clinical pharmacists and prescribers. Always consult the most current prescribing information and relevant guidelines for definitive guidance.*