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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production.
## Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD)
* Maintenance of healing of erosive esophagitis
* Treatment of pathological hypersecretory conditions (e.g., 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. Some patients may be treated with 20 mg orally once daily.
* **Pathological hypersecretory conditions:** 40 mg orally or intravenously twice daily, may be increased to 80 mg intravenously or orally twice daily. Doses above 80 mg daily should be divided and administered every 12 hours.
## Pediatric Dosing
* **12 to 17 years:**
* **Erosive esophagitis:** 40 mg orally once daily for up to 4 weeks.
* **5 to 11 years:**
* **Erosive esophagitis:** 20 mg orally once daily for up to 4 weeks. May be considered for an additional 4 weeks if healing is not complete.
* **Note:** Intravenous formulation is not approved for pediatric use.
## Dose Adjustments
No dose adjustment is typically necessary for hepatic impairment, though caution may be warranted with severe impairment. No dose adjustment is needed for renal impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, and rash. Long-term use may increase the risk of *Clostridium difficile*-associated diarrhea, bone fractures, hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** PPIs can decrease the absorption of drugs like ketoconazole, itraconazole, iron salts, and certain protease inhibitors (e.g., atazanavir, nelfinavir).
* **Methotrexate:** Coadministration with PPIs may increase methotrexate levels, potentially leading to toxicity.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution is advised when coadministering with drugs primarily metabolized by CYP2C19, such as clopidogrel (though clinical significance is debated) and diazepam.
## Monitoring
* Monitor for signs and symptoms of *Clostridium difficile*-associated diarrhea.
* Consider monitoring serum magnesium levels in patients on long-term therapy, especially if taking concomitant medications like digoxin or diuretics.
* Monitor for signs of bone fracture in patients at risk.
* Monitor for signs and symptoms of vitamin B12 deficiency with prolonged use.
## Clinical Pearls
* Pantoprazole is generally considered to have fewer drug interactions compared to omeprazole due to its weaker inhibition of CYP2C19.
* Oral formulations should be taken at least 1 hour before a meal.
* Pantoprazole delayed-release tablets should be swallowed whole and not crushed or chewed.
* Intravenous administration requires reconstitution and dilution; follow manufacturer instructions carefully.
* The efficacy and safety of pantoprazole for GERD symptom management without evidence of erosive esophagitis are not established for long-term use.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the current prescribing information and relevant guidelines before making clinical decisions.
