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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production.
## Primary Indications
* Erosive esophagitis associated with gastroesophageal reflux disease (GERD)
* Maintenance of healing of erosive esophagitis
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
* *H. pylori* eradication (in combination with antibiotics)
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily. Doses of 20 mg orally may be sufficient for some patients.
* **Pathological hypersecretory conditions:** Starting dose is 40 mg orally or intravenously twice daily. Doses may be increased up to 240 mg intravenously or 960 mg orally per day divided into two doses.
* ***H. pylori* eradication:** 40 mg orally twice daily for 7-14 days in combination with amoxicillin 1000 mg orally twice daily and clarithromycin 500 mg orally twice daily, or with clarithromycin 500 mg orally twice daily and metronidazole 500 mg orally twice daily. Alternative regimens exist.
## Pediatric Dosing
Dosing varies by indication and age. Consult specific pediatric guidelines.
* **Erosive esophagitis (1 to 11 years):** 20-40 mg orally once daily based on weight (<40 kg: 20 mg; ≥40 kg: 40 mg).
* **Erosive esophagitis (≥12 years):** 40 mg orally once daily.
* **GERD (5 to 11 years):** 20-30 mg orally once daily.
* **GERD (≥12 years):** 40 mg orally once daily.
## Dose Adjustments
No dose adjustment is typically needed for renal impairment.
For severe hepatic impairment, a dose of 20 mg orally once daily is recommended.
## Contraindications
Hypersensitivity to pantoprazole, substituted benzimidazoles, 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:
* Fractures (hip, wrist, spine)
* Clostridium difficile infection
* Hypomagnesemia
* Vitamin B12 deficiency
* Fundic gland polyps
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, iron salts, nelfinavir, rilpivirine. Pantoprazole can decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates/inhibitors:** Pantoprazole is a moderate inhibitor of CYP2C19. Monitor for potential toxicity with concomitant use of drugs like clopidogrel (though clinical significance is debated).
## Monitoring
* Monitor for signs and symptoms of *Clostridium difficile* infection.
* Consider monitoring magnesium levels in patients on long-term therapy, especially those taking diuretics.
* Assess for signs of vitamin B12 deficiency with prolonged use.
* Evaluate bone mineral density in patients at risk for osteoporosis.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes before a meal.
* Delayed-release tablets should be swallowed whole and not chewed or crushed.
* For IV administration, reconstitute and dilute according to manufacturer instructions. Infusion should be over at least 15 minutes.
* PPIs are intended for short-term treatment; reassess need for continued therapy.
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*Disclaimer: This information is intended for clinical use and does not replace professional medical advice. Always verify current prescribing information with the official product monograph or reliable drug information resources.*
