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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid secretion.
## Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Reduction of the risk of NSAID-associated gastric ulcers in patients at risk.
* Pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily.
* **NSAID-associated gastric ulcers:** 40 mg orally once daily. For patients with a history of gastric ulcers, may be continued for up to 1 year.
* **Hypersecretory conditions (e.g., Zollinger-Ellison syndrome):** Starting dose is 40 mg orally or intravenously twice daily. Doses may be increased as clinically needed. Doses up to 240 mg daily have been administered intravenously.
## Pediatric Dosing
* **Erosive esophagitis (5 to 16 years):** 20 mg or 40 mg orally once daily for up to 8 weeks. Dose selection depends on body weight.
* Patients weighing < 40 kg: 20 mg once daily.
* Patients weighing ≥ 40 kg: 40 mg once daily.
* **Erosive esophagitis (≥ 17 years):** Same as adult dosing.
## Dose Adjustments
* **Hepatic Impairment:** Maximum dose of 40 mg once daily orally. Intravenous formulation is not recommended.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia (can be severe, may lead to hypocalcemia, hypokalemia, tetany, seizures, and cardiac arrhythmias), vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Antiretrovirals:** Drugs requiring gastric acidity for absorption (e.g., nelfinavir, atazanavir) may have decreased efficacy.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. Consider dose interruption.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Monitor for effects when co-administered with drugs extensively metabolized by this enzyme (e.g., clopidogrel, voriconazole, fluconazole).
* **Warfarin:** May increase INR and prothrombin time. Monitor INR closely.
## Monitoring
* Magnesium levels, especially with long-term use (>3 months) or concurrent diuretic use.
* Vitamin B12 levels with prolonged therapy (>3 years).
* Bone mineral density in patients at risk for osteoporosis.
## Clinical Pearls
* Administer orally 30 minutes before a meal.
* If taking pantoprazole orally disintegrating tablets, instruct patients to place the tablet on the tongue and allow it to disintegrate completely before swallowing. Do not chew or crush.
* For intravenous administration, reconstitute and dilute as per manufacturer instructions.
* Long-term use of PPIs may be associated with an increased risk of certain adverse events. Use the lowest effective dose for the shortest duration necessary.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and guidelines for complete and up-to-date details on drug indications, dosages, contraindications, warnings, precautions, adverse effects, and drug interactions.
