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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Healing of erosive esophagitis
* Maintenance of healing of erosive esophagitis
* Symptomatic gastroesophageal reflux disease (GERD)
* 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 Erosive Esophagitis:** 40 mg orally once daily.
* **Symptomatic GERD:** 20 mg orally once daily for up to 4 weeks. If symptoms do not resolve, consider further evaluation.
* **Pathological Hypersecretory Conditions:** Starting dose is 40 mg orally or intravenously twice daily. Doses may be increased as needed. Doses greater than 240 mg daily should be administered intravenously in divided doses.
* **Maximum Dose:** Generally 40 mg orally twice daily or 40 mg intravenously twice daily. For pathological hypersecretory conditions, higher doses may be used under specialist supervision.
## Pediatric Dosing
* **Erosive Esophagitis (1 to 5 years):** 10 mg orally once daily for up to 8 weeks.
* **Erosive Esophagitis (5 to 16 years):** 20 mg orally once daily for up to 8 weeks.
* **Symptomatic GERD (1 to 5 years):** 10 mg orally once daily for up to 4 weeks.
* **Symptomatic GERD (5 to 16 years):** 20 mg orally once daily for up to 4 weeks.
* *Note: IV formulations are not typically recommended for pediatric use.*
* *Dosing for pediatric patients with pathological hypersecretory conditions is not well established and should be managed by a specialist.*
## Dose Adjustments
* **Hepatic Impairment:** For oral formulations, the maximum dose is 20 mg once daily. No dose adjustment is needed for IV formulations in mild to moderate hepatic impairment, but caution is advised. Severe hepatic impairment data is limited for IV.
## Contraindications
* Known hypersensitivity to pantoprazole, its components, or other PPIs.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, hypomagnesemia (can be severe and lead to arrhythmias, seizures, tremors), vitamin B12 deficiency with long-term use, lupus erythematosus (cutaneous and systemic).
## Key Drug Interactions
* **Ketoconazole, Itraconazole, Posaconazole, Erlotinib:** Pantoprazole can decrease absorption due to reduced gastric acidity.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **Rilpivirine, Nelfinavir:** Concurrent use is generally not recommended.
* **Warfarin:** Increased INR and bruising may occur. Monitor INR closely.
* **Sucralfate:** May decrease pantoprazole absorption. Administer pantoprazole at least 30 minutes before sucralfate.
## Monitoring
* Electrolytes (especially magnesium, potassium, calcium) with prolonged use.
* Vitamin B12 levels with prolonged use.
* Bone mineral density with prolonged use, especially in patients with risk factors.
* Signs and symptoms of *C. difficile* infection.
* Renal function in patients with severe hepatic impairment receiving IV pantoprazole.
## Clinical Pearls
* Oral pantoprazole should be taken at least 30 minutes before a meal for optimal efficacy.
* Do not crush or chew delayed-release capsules or tablets.
* Long-term PPI use is associated with increased risk of fractures, C. difficile infection, and hypomagnesemia. Assess the need for continued therapy periodically.
* IV pantoprazole should be administered as a slow infusion over 15 minutes or as a continuous infusion.
* For patients on long-term therapy, consider the lowest effective dose.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making therapeutic decisions.*
