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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases 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, including Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally once daily for up to 8 weeks. For maintenance of healing, 40 mg orally once daily may be continued.
* **Pathological hypersecretory conditions:** Starting dose typically 40 mg orally twice daily, may be increased. Doses up to 240 mg daily have been administered intravenously. Maximum oral dose not well-established but generally considered 40 mg twice daily.
## Pediatric Dosing
* **Erosive esophagitis:**
* 1-5 years: 10 mg orally once daily for up to 8 weeks.
* 6-11 years: 20 mg orally once daily for up to 8 weeks.
* 12-16 years: 40 mg orally once daily for up to 8 weeks.
* Dosing for pathological hypersecretory conditions in pediatrics is not well-established and requires specialist consultation.
## Dose Adjustments
* **Hepatic impairment:** Maximum daily dose is 40 mg orally once daily.
* **Renal impairment:** No dose adjustment needed.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of its formulation.
## Adverse Effects
Common: Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
Serious: *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency, lupus erythematosus (cutaneuous and systemic).
## Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** Antiretrovirals (e.g., rilpivirine, atazanavir), antifungals (e.g., ketoconazole, itraconazole), iron salts. May decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Monitor for potential effects on drugs like clopidogrel, though clinical significance is debated.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremor, muscle cramps, seizures).
* Long-term use may warrant monitoring of vitamin B12 levels and bone mineral density.
* Assess for efficacy and need for continued therapy, especially after 8 weeks for erosive esophagitis.
## Clinical Pearls
* Administer delayed-release tablets 30 minutes before a meal.
* Do not crush or chew delayed-release tablets.
* If pantoprazole is used for more than 3 months, it may cause hypomagnesemia, and if used for more than a year, it may cause vitamin B12 deficiency.
* Consider lowest effective dose for the shortest duration necessary.
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*This information is intended for healthcare professionals and does not substitute for comprehensive prescribing information. Always consult the current official prescribing information and institutional protocols.*
