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# Pantoprazole ## Overview Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion. ## 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 (ZES). ## Adult Dosing * **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks. * **Maintenance of Healing:** 40 mg orally once daily. * **Pathological Hypersecretory Conditions (ZES):** 40 mg orally twice daily, may be increased as needed. Doses up to 240 mg daily have been administered. ## Pediatric Dosing * **GERD and Erosive Esophagitis (12 years and older):** 40 mg orally once daily for up to 8 weeks. * **GERD and Erosive Esophagitis (5-11 years):** 20-40 mg orally once daily, depending on weight (20 mg for < 55 kg, 40 mg for ≥ 55 kg), for up to 8 weeks. * **GERD and Erosive Esophagitis (less than 5 years):** Dosing is not established. Use with caution and under strict medical supervision if prescribed. ## Dose Adjustments No dose adjustment is typically required for renal impairment. In severe hepatic impairment, a dose of 20 mg once daily may be sufficient. ## Contraindications * Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation. ## Adverse Effects Common: Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness. Less Common: Arthralgia, myalgia, rash, pruritus. Rare: Severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis), Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine) with long-term use, hypomagnesemia with long-term use. ## Key Drug Interactions * **Drugs Dependent on Gastric pH for Absorption:** Ketoconazole, itraconazole, posaconazole, iron salts, mycophenolate mofetil, rilpivirine. Concomitant use may decrease absorption. * **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. * **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution advised with concomitant use of drugs primarily metabolized by CYP2C19 (e.g., clopidogrel, voriconazole). ## Monitoring * Monitor for signs and symptoms of fractures, hypomagnesemia, and C. difficile infection with long-term use. * For ZES, monitor gastric pH and acid output. ## Clinical Pearls * Administer orally 30 minutes to 1 hour before a meal. * For patients with difficulty swallowing, pantoprazole delayed-release tablets can be mixed with applesauce or a similar food product. Do not crush or chew the tablets. * Long-term PPI therapy (over 1 year) may be associated with an increased risk of C. difficile infection, bone fractures, and hypomagnesemia. *** *Please verify current prescribing information and institutional protocols before initiating or modifying therapy.*