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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Gastroesophageal reflux disease (GERD)
* Erosive esophagitis healing and maintenance
* Zollinger-Ellison syndrome
* Part of H. pylori eradication regimens
## Adult Dosing
* **GERD/Erosive Esophagitis:** 40 mg orally or intravenously once daily for 4-8 weeks. Maintenance therapy: 20-40 mg once daily.
* **Zollinger-Ellison Syndrome:** 40 mg orally or intravenously twice daily. Dose may be increased to 80 mg intravenously every 8 hours or 160 mg intravenously every 12 hours. Max: 160 mg/day.
* **H. pylori Eradication:** 40 mg orally twice daily for 7-14 days in combination with antibiotics (e.g., amoxicillin, clarithromycin, metronidazole) and potentially bismuth subsalicylate.
## Pediatric Dosing
* **GERD/Erosive Esophagitis:**
* **12 to <17 years:** 40 mg orally once daily for up to 8 weeks.
* **5 to <12 years:** 20 mg orally once daily for up to 8 weeks. Dose may be increased to 40 mg orally once daily.
* **1 month to <5 years:** Intravenous formulation is available but pediatric oral dosing is not well established for this age group. Consult specific pediatric guidelines or literature. IV dosing in children <12 years is typically 0.5-1.5 mg/kg/day divided q12-24h.
## Dose Adjustments
* **Hepatic Impairment:** Oral: Maximum dose 20 mg once daily. Intravenous: Maximum dose 20 mg once daily.
## Contraindications
* Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness.
* **Serious:** Fundic gland polyps (long-term use), *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with prolonged use, hypomagnesemia, vitamin B12 deficiency, potential increased risk of pneumonia.
## Key Drug Interactions
* **Certain Antiretrovirals (e.g., rilpivirine, atazanavir):** Decreased absorption due to increased gastric pH. Avoid coadministration.
* **Methotrexate:** Increased methotrexate levels and toxicity. Monitor closely and consider dose reduction.
* **Drugs Dependent on Gastric pH for Absorption (e.g., ketoconazole, itraconazole, iron salts):** Decreased absorption.
* **Warfarin:** Increased INR and bleeding risk. Monitor INR closely.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremors, muscle cramps, seizures, arrhythmias).
* Monitor for signs of *C. difficile* infection.
* Consider monitoring B12 levels with prolonged therapy.
* Monitor bone mineral density in patients at risk for osteoporosis.
## Clinical Pearls
* Administer oral pantoprazole at least 30 minutes before a meal.
* Delayed-release tablets and granules should be swallowed whole and not chewed, cut, or crushed.
* For IV administration, reconstitute and further dilute per manufacturer instructions.
* The risk of fracture, C. difficile infection, and hypomagnesemia may increase with higher doses and longer duration of use.
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*This information is intended for clinical professionals. Always consult the current prescribing information and relevant literature for complete details. Dosing may vary based on specific patient factors and local protocols.*
