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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, such as Zollinger-Ellison syndrome.
## 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:** Doses range from 40 mg orally once daily to 40 mg orally twice daily. The maximum dose is typically 80 mg daily, but higher doses may be used cautiously under expert supervision.
## Pediatric Dosing
* **Erosive esophagitis (1-17 years):** 20 mg orally once daily for up to 4 weeks. If not healed, may consider up to 8 weeks of therapy.
* **Erosive esophagitis (children < 1 year):** Dosing is not well-established and should be based on clinical judgment and expert consultation. Limited data suggest a range of 0.5 mg/kg to 1.3 mg/kg once daily.
## Dose Adjustments
No dose adjustment is generally required for hepatic impairment, though some sources suggest caution with severe impairment and potential dose reduction. No dose adjustment is needed for renal impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* Common: Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
* Long-term use: May be associated with an increased risk of *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs requiring gastric pH for absorption:** Ketoconazole, itraconazole, iron salts, delavirdine, nelfinavir. Pantoprazole can decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19.
## Monitoring
* Monitor for signs and symptoms of *C. difficile* infection.
* Consider serum magnesium levels, especially with prolonged use (typically >1 year) or concurrent diuretic use.
* Monitor for signs and symptoms of bone fractures.
* Monitor for signs and symptoms of vitamin B12 deficiency.
## Clinical Pearls
* Administer 30-60 minutes before a meal for optimal efficacy.
* Do not crush or chew delayed-release formulations; swallow whole.
* The intravenous formulation is a
