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Pantoprazole is a proton pump inhibitor (PPI).
### Primary Indications
* Erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Pathological hypersecretory conditions, such as Zollinger-Ellison syndrome.
* Healing of duodenal ulcers.
* Maintenance of healing of erosive esophagitis and duodenal ulcers.
### Adult Dosing
* **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks. For maintenance, 40 mg orally once daily.
* **Duodenal Ulcers:** 40 mg orally once daily for up to 4 weeks.
* **Pathological Hypersecretory Conditions:** Starting dose is typically 40 mg orally twice daily, but can be increased as needed. Usual maximum dose is 240 mg daily. Doses > 80 mg should be divided and given twice daily.
### Pediatric Dosing
* **GERD (erosive esophagitis):**
* **1 to <5 years:** 10 mg orally once daily for up to 8 weeks.
* **5 to <12 years:** 20 mg orally once daily for up to 8 weeks.
* **12 to 16 years:** 40 mg orally once daily for up to 8 weeks.
* **GERD (symptomatic):**
* **1 to <5 years:** 10 mg orally once daily for up to 4 weeks.
* **5 to <12 years:** 20 mg orally once daily for up to 4 weeks.
* **12 to 16 years:** 40 mg orally once daily for up to 4 weeks.
Note: Dosing in pediatrics is often based on local protocol and physician discretion, especially for conditions beyond GERD.
### Dose Adjustments
* **Hepatic Impairment:** Maximum dose is 20 mg orally once daily for patients with severe hepatic impairment.
* **Renal Impairment:** No dose adjustment necessary.
### Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
### Adverse Effects
* Common: Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness.
* Long-term use (over 1 year): Increased risk of Clostridioides difficile infection, bone fractures (hip, wrist, spine), magnesium deficiency (hypomagnesemia), and vitamin B12 deficiency.
### Key Drug Interactions
* **Drugs Dependent on Gastric pH:** Pantoprazole can decrease gastric acidity, potentially affecting the absorption of drugs requiring an acidic environment (e.g., ketoconazole, itraconazole, certain HIV protease inhibitors).
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. Consider temporary discontinuation of pantoprazole.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution with drugs primarily metabolized by this enzyme (e.g., clopidogrel, citalopram, escitalopram).
### Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremors, seizures, arrhythmias) with long-term therapy.
* Consider monitoring magnesium levels, especially in patients on concomitant diuretic therapy or taking other medications known to lower magnesium levels.
* Monitor for signs of bone fracture with long-term use.
* Monitor for signs of vitamin B12 deficiency with prolonged therapy.
### Clinical Pearls
* Administer pantoprazole 30 minutes before a meal for optimal efficacy.
* Delayed-release tablets should be swallowed whole and not chewed or crushed.
* For patients unable to swallow tablets, pantoprazole for delayed-release oral suspension can be used. Reconstitute and administer within 30 minutes.
* IV formulation is available for patients unable to take oral medications.
* The FDA has updated its labeling to recommend that PPIs should not be used for more than 14 days unless directed by a healthcare provider. The maximum duration of treatment with a PPI for most conditions should not exceed 8 to 16 weeks.
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*Disclaimer: This information is intended for clinical professionals and does not replace current prescribing information. Always verify with the most recent product monograph and local guidelines.*
