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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 Healing:** 40 mg orally or intravenously once daily for up to 8 weeks. * **Erosive Esophagitis Maintenance:** 40 mg orally once daily. For some patients, 20 mg orally once daily may be sufficient. * **NSAID-Associated Ulcer Prevention:** 40 mg orally once daily. * **Pathological Hypersecretory Conditions:** 40 mg orally or intravenously twice daily. Doses may be increased as needed. Doses up to 240 mg intravenously daily have been given. ## Pediatric Dosing * **1 year to 5 years:** 10 mg orally once daily for erosive esophagitis. * **5 years to 16 years:** 20 mg orally once daily for erosive esophagitis. * **Note:** Dosing for children is often based on institutional protocols and clinical judgment. Intravenous formulations are not typically recommended for pediatric use unless clinically necessary and under specialist guidance. ## Dose Adjustments No dose adjustment is typically required for renal impairment. In severe hepatic impairment, the maximum daily dose should not exceed 40 mg orally or 20 mg intravenously once daily. ## Contraindications * Known hypersensitivity to pantoprazole or any component of the formulation. * Use of rilpivirine-containing products. ## Adverse Effects Common: Diarrhea, headache, dizziness, abdominal pain, nausea, vomiting. Long-term use may be associated with an increased risk of *Clostridioides difficile*-associated diarrhea, bone fractures, hypomagnesemia, and vitamin B12 deficiency. ## Key Drug Interactions * **Antiretrovirals:** Pantoprazole can decrease absorption of drugs like rilpivirine, atazanavir, and nelfinavir. * **Methotrexate:** PPIs may increase methotrexate levels. * **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19; consider potential for increased levels of drugs metabolized by this enzyme (e.g., clopidogrel, though clinical significance is debated). * **Iron salts, azole antifungals:** Reduced absorption due to decreased gastric acidity. ## Monitoring * Monitor for signs and symptoms of *Clostridioides difficile*-associated diarrhea. * Consider monitoring serum magnesium levels with prolonged therapy (>3 months), especially in patients taking concomitant medications known to cause hypomagnesemia (e.g., diuretics). * Assess for signs of bone fracture in patients at risk with long-term use. * Monitor for signs and symptoms of vitamin B12 deficiency with long-term use. ## Clinical Pearls * Administer oral pantoprazole 30 minutes before a meal. * Delayed-release formulations should not be crushed or chewed. * Intravenous administration should be over at least 2 minutes. * The risk of bone fractures increases with higher doses and longer duration of therapy. * Hypomagnesemia can be asymptomatic or manifest as fatigue, muscle spasms, seizures, or arrhythmias. *** **Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and product labeling, or consult with a pharmacist, before making any treatment decisions. Dosing and recommendations may vary based on patient-specific factors and local protocols.