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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases the amount of acid produced in the stomach.
## Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Treatment of pathological hypersecretory conditions, such as Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily. Some patients may be treated with 20 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose of 40 mg orally or intravenously twice daily. Doses may be increased as needed. Doses up to 240 mg intravenously daily have been administered.
## Pediatric Dosing
* **Erosive esophagitis (age 5 to 16 years):** 20 mg orally once daily for up to 8 weeks.
* **Erosive esophagitis (age 5 to 16 years):** 40 mg orally once daily for up to 8 weeks for those not healed on 20 mg.
There is limited data for pediatric use in other indications.
## Dose Adjustments
No dose adjustment is typically needed for hepatic or renal impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, flatulence, and dizziness. Long-term use of PPIs may be associated with an increased risk of *Clostridioides difficile*-associated diarrhea, bone fractures, hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** PPIs can decrease the absorption of drugs such as ketoconazole, itraconazole, and certain HIV protease inhibitors (e.g., atazanavir).
* **Methotrexate:** Concomitant use may increase and prolong serum levels of methotrexate, potentially leading to toxicity.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution may be warranted when used with substrates like clopidogrel, though clinical significance is debated.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremor, tetany, seizures).
* Monitor for signs and symptoms of *Clostridioides difficile*-associated diarrhea.
* Assess for fracture risk in patients on long-term therapy.
* Consider vitamin B12 levels in patients with long-term therapy and symptoms of deficiency.
## Clinical Pearls
* Administer pantoprazole delayed-release tablets 30 minutes before a meal.
* Intravenous pantoprazole is typically reconstituted and then further diluted for infusion.
* PPIs should be used at the lowest effective dose for the shortest duration necessary to treat the condition.
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This information is intended for healthcare professionals and does not replace the need to consult the most current prescribing information and clinical guidelines. Always verify current prescribing information before making clinical decisions.
