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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, including Zollinger-Ellison syndrome.
### Adult Dosing
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing erosive esophagitis:** 40 mg orally once daily. Some patients may be treated with 20 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose is 40 mg orally or intravenously twice daily. Doses can be increased to 240 mg intravenously or 960 mg orally per day divided into two doses. Typical doses range from 40 mg twice daily to 220 mg twice daily.
### Pediatric Dosing
* **Erosive esophagitis (ages 5-16 years):** 40 mg orally once daily for up to 4 weeks.
* **GERD (ages 5-16 years):** 20 mg orally once daily for up to 8 weeks.
* Dosing for pediatric patients with pathological hypersecretory conditions is not established.
### Dose Adjustments
No dose adjustment is typically needed for patients with hepatic or renal impairment.
### Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
### Adverse Effects
Common adverse effects include diarrhea, headache, nausea, dizziness, and abdominal pain. Long-term use of PPIs may be associated with an increased risk of fracture (hip, wrist, spine), *Clostridium difficile*-associated diarrhea, vitamin B12 deficiency, and hypomagnesemia.
### Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** PPIs can decrease absorption of drugs like ketoconazole, itraconazole, and certain HIV protease inhibitors (e.g., atazanavir, nelfinavir).
* **Methotrexate:** PPIs may increase levels of methotrexate.
* **CYP2C19 substrates/inhibitors:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution is advised when co-administered with drugs heavily metabolized by this enzyme, such as clopidogrel.
### Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremor, tetany, seizures, arrhythmias).
* Monitor for signs of *Clostridium difficile*-associated diarrhea.
* Consider periodic monitoring of magnesium and vitamin B12 levels in patients on long-term therapy.
### Clinical Pearls
* For oral administration, pantoprazole delayed-release tablets should be swallowed whole and not crushed or chewed.
* The IV formulation should be administered as a slow infusion over at least 2 minutes.
* Avoid concomitant use with St. John's Wort or rifampin.
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**Disclaimer:** This information is intended for clinical decision-making and is not a substitute for professional medical advice. Always consult the most current prescribing information, institutional protocols, and relevant literature for complete and up-to-date guidance.
