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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases gastric acid production.
## Primary Indications
* Gastroesophageal reflux disease (GERD)
* Erosive esophagitis
* Healing of duodenal ulcers
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
* H. pylori eradication (in combination with antibiotics)
## Adult Dosing
* **GERD/Erosive Esophagitis:** 40 mg orally or intravenously once daily. Duration typically 4-8 weeks.
* **Duodenal Ulcers:** 40 mg orally or intravenously once daily. Duration typically 4 weeks.
* **Pathological Hypersecretory Conditions:** Start with 40 mg orally or intravenously twice daily. Doses may be increased as needed. Maximum oral dose is 240 mg daily in divided doses. Maximum IV dose is 90 mg every 8 hours.
* **H. pylori Eradication:** 40 mg orally twice daily for 7-14 days in combination with amoxicillin and clarithromycin, or with clarithromycin and metronidazole.
## Pediatric Dosing
* **GERD/Erosive Esophagitis:**
* **1 month to < 5 years:** 20 mg orally once daily.
* **5 years to < 12 years:** 20 mg orally once daily. May increase to 40 mg once daily if needed.
* **12 years to 16 years:** 40 mg orally once daily.
* IV dosing in pediatric patients is less well-established and often reserved for situations where oral administration is not feasible. Doses vary based on weight and clinical indication. Consult specialized pediatric resources for IV dosing.
## Dose Adjustments
* **Hepatic Impairment:** For severe hepatic impairment, consider reducing the dose to 20 mg orally once daily.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Concomitant use with rilpivirine.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
* **Serious:** *Clostridioides difficile*-associated diarrhea (CDAD), bone fracture (hip, wrist, spine) with long-term, high-dose use, hypomagnesemia (particularly with prolonged use >1 year), vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Rilpivirine:** Pantoprazole decreases rilpivirine absorption; contraindicated.
* **Antiretrovirals (other):** May decrease absorption of certain antiretrovirals (e.g., atazanavir, nelfinavir).
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity.
* **Drugs dependent on gastric pH for absorption:** May alter absorption of drugs like ketoconazole, itraconazole, iron salts, and cyanocobalamin.
* **CYP2C19 substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs metabolized by this enzyme (e.g., clopidogrel, voriconazole).
## Monitoring
* Monitor for signs and symptoms of CDAD.
* Consider magnesium levels with prolonged therapy (>3 months), especially in patients taking diuretics.
* Monitor for signs of vitamin B12 deficiency with prolonged therapy (>3 years).
* Bone mineral density screening in patients at risk for osteoporosis.
## Clinical Pearls
* Pantoprazole is generally considered to have fewer CYP2C19 interactions compared to omeprazole or esomeprazole, but caution is still advised.
* IV administration is not bioequivalent to oral administration.
* Discontinuation of PPIs should ideally be gradual to prevent rebound acid hypersecretion, though abrupt cessation is common.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for definitive guidance. Dosing may vary based on individual patient factors and local protocols.*
