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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion by irreversibly blocking the H+/K+ ATPase enzyme system in gastric parietal cells.
## Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Treatment of pathological hypersecretory conditions, including Zollinger-Ellison Syndrome.
* Reduction of risk of NSAID-associated gastric ulcers in patients at risk.
## Adult Dosing
* **Healing of Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of Healing of Erosive Esophagitis:** 40 mg orally once daily. May consider 20 mg orally once daily.
* **Pathological Hypersecretory Conditions (e.g., Zollinger-Ellison Syndrome):** 40 mg orally or intravenously twice daily. Doses may be increased as needed. Usual doses range from 40 mg to 120 mg daily. Doses greater than 80 mg daily should be divided and administered twice daily.
* **Reduction of NSAID-associated Gastric Ulcers:** 40 mg orally once daily.
## Pediatric Dosing
* **Erosive Esophagitis (12 years and older):** 40 mg orally once daily for up to 4 weeks. If not healed, continue for an additional 4 weeks.
* **Erosive Esophagitis (5 to 11 years):** 20 mg orally once daily for up to 4 weeks. If not healed, continue for an additional 4 weeks.
* **Erosive Esophagitis (less than 5 years):** Dosing not established.
## Dose Adjustments
* **Hepatic Impairment:** Maximum dose is 40 mg orally or intravenously once daily.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Concomitant use with rilpivirine-containing products.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness.
* **Serious:** Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia (can be severe and prolonged), vitamin B12 deficiency, fundic gland polyps.
* **Rare:** Acute interstitial nephritis, systemic lupus erythematosus.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Antiretrovirals (e.g., rilpivirine, nelfinavir), antifungals (e.g., ketoconazole, itraconazole), iron salts, mycophenolate mofetil.
* **CYP2C19 substrates:** May increase levels of drugs metabolized by CYP2C19 (e.g., clopidogrel, warfarin, phenytoin).
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity.
## Monitoring
* Monitor for signs and symptoms of Clostridium difficile infection.
* Monitor magnesium levels, especially in patients with prolonged PPI use (typically >1 year) or those taking concomitant medications that can lower magnesium levels (e.g., diuretics).
* Monitor for signs of bone fracture.
* Assess for vitamin B12 deficiency with prolonged use.
## Clinical Pearls
* Oral pantoprazole is generally preferred over IV for patients who can swallow pills.
* Long-term use of PPIs may be associated with increased risk of C. difficile infection, bone fractures, and hypomagnesemia. Consider the risks and benefits for extended therapy.
* Discontinue PPIs gradually if possible to minimize rebound acid hypersecretion.
* Parenteral formulations should be reconstituted and diluted as per manufacturer instructions. Reconstituted solution is stable for 24 hours at room temperature.
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*Please verify current prescribing information for the most up-to-date details.*
