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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 and erosive esophagitis
* 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 once daily for up to 8 weeks. For maintenance of healing, 40 mg once daily may be continued; some patients may be treated with 20 mg once daily.
* **NSAID-Induced Ulcer Prophylaxis:** 20 mg or 40 mg once daily.
* **Pathological Hypersecretory Conditions:** 40 mg twice daily initially, may be increased as needed. Usual dose range 40 mg to 80 mg daily. Doses above 80 mg daily should be divided and administered every 12 hours. Maximum dose generally 120 mg daily.
### Pediatric Dosing
* **GERD/Erosive Esophagitis:**
* **1-5 years (15-25 kg):** 20 mg once daily for up to 8 weeks.
* **6-11 years (25-40 kg):** 20 mg once daily for up to 8 weeks; may consider 40 mg once daily if needed.
* **12-17 years:** 40 mg once daily for up to 8 weeks.
* Dosing above 40 mg daily in children has not been established.
### Dose Adjustments
* **Hepatic Impairment:** Maximum dose of 20 mg once daily.
* **Renal Impairment:** No dose adjustment needed.
### Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Use of rilpivirine-containing products.
### Adverse Effects
* Headache, diarrhea, nausea, abdominal pain, vomiting, flatulence, dizziness.
* Long-term use may be associated with *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency, and potentially an increased risk of certain infections (e.g., *Salmonella*, *Campylobacter*).
### Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, posaconazole, iron salts, mycophenolate mofetil. Pantoprazole can decrease absorption.
* **CYP2C19 substrates:** Clopidogrel (potential reduced efficacy).
* **Methotrexate:** PPIs may increase methotrexate levels.
* **Rilpivirine:** Contraindicated due to risk of virologic failure.
* **Sucralfate:** May decrease pantoprazole absorption; administer 30 minutes before sucralfate.
### Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremor, tetany, seizures, muscle cramps) especially with prolonged use (≥ 1 year). Consider baseline and periodic magnesium levels.
* Monitor for signs of *Clostridioides difficile* infection.
* Assess for bone fracture risk in patients on long-term therapy.
* Consider vitamin B12 levels for patients with long-term therapy or risk factors for deficiency.
### Clinical Pearls
* Administer 30-60 minutes before meals.
* Do not crush or chew delayed-release tablets/capsules.
* IV formulation is available for patients unable to take oral medications.
* Long-term use should be reserved for those with documented need.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making therapeutic decisions.
