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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces the amount of acid produced in the stomach.
## Primary Indications
* Gastroesophageal reflux disease (GERD)
* Erosive esophagitis
* Healing of erosive esophagitis
* Zollinger-Ellison syndrome
* Reduction of risk of NSAID-associated gastric ulcers in patients taking NSAIDs.
## Adult Dosing
* **GERD & Erosive Esophagitis:** 20 mg to 40 mg orally once daily.
* **Healing of Erosive Esophagitis:** 40 mg orally once daily.
* **Zollinger-Ellison Syndrome:** 40 mg orally twice daily. The dose may be adjusted upwards based on gastric acid output. Doses up to 240 mg daily have been administered.
* **NSAID-Associated Ulcer Prophylaxis:** 20 mg orally once daily.
Intravenous (IV) dosing is also available for patients unable to take oral medication. Typical IV doses are 40 mg daily.
## Pediatric Dosing
* **GERD & Erosive Esophagitis (ages 5-16 years):** 20 mg orally once daily.
* **GERD & Erosive Esophagitis (ages 1-5 years):** 10 mg to 20 mg orally once daily, depending on weight.
Dosing for younger children and for other indications in pediatrics is less established.
## Dose Adjustments
No dose adjustment is generally required for renal impairment. In severe hepatic impairment, a maximum daily dose of 20 mg is recommended.
## Contraindications
Known hypersensitivity to pantoprazole or any of its components.
## Adverse Effects
Common side effects include headache, diarrhea, nausea, abdominal pain, and dizziness. Long-term PPI use may be associated with an increased risk of:
* Fractures (hip, wrist, spine)
* Clostridium difficile infection
* Vitamin B12 deficiency
* Hypomagnesemia
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Absorption of certain drugs (e.g., ketoconazole, itraconazole, some HIV protease inhibitors) may be decreased due to reduced gastric acidity.
* **Methotrexate:** Co-administration with PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution is advised when used with drugs metabolized by this enzyme (e.g., clopidogrel, though clinical significance is debated).
## Monitoring
Monitor for signs and symptoms of adverse effects, particularly with long-term use. Consider magnesium levels with prolonged therapy, especially if concomitant diuretic or digoxin use. Monitor for signs of C. difficile infection.
## Clinical Pearls
* Administer pantoprazole orally 30-60 minutes before a meal.
* Do not crush or chew delayed-release formulations.
* IV administration should be completed over 15 minutes.
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*Please consult the most current prescribing information for complete details and to verify all dosage and safety information before use.*
