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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion by irreversibly inhibiting the H+/K+-ATPase enzyme system (the proton pump) in gastric parietal cells.
## Primary Indications
* Healing of erosive esophagitis
* Maintenance of healing of erosive esophagitis
* Treatment of pathological hypersecretory conditions, including Zollinger-Ellison syndrome (ZES)
* Treatment of gastroesophageal reflux disease (GERD)
## Adult Dosing
* **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks. For maintenance, 40 mg orally once daily.
* **GERD:** 20 mg orally once daily for up to 4 weeks.
* **Pathological Hypersecretory Conditions (e.g., ZES):** Starting dose is 40 mg orally twice daily. Doses may be increased to 240 mg/day given in divided doses.
**Maximum dose:** 240 mg daily.
## Pediatric Dosing
Dosing varies based on age and indication. Consult specific pediatric guidelines or resources for precise recommendations.
* **Erosive Esophagitis (ages 5 to 16 years):** 20 mg orally once daily for up to 4 weeks.
* **Erosive Esophagitis (ages 5 to 16 years, more severe disease):** 40 mg orally once daily for up to 8 weeks.
## Dose Adjustments
* **Hepatic Impairment:** Reduce the daily dose to 20 mg orally once daily.
* **Renal Impairment:** No dose adjustment is typically required.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, flatulence.
* **Serious:** *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, hypomagnesemia (can be severe), fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Absorption may be decreased (e.g., ketoconazole, itraconazole, iron salts, vitamin B12).
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs metabolized by this enzyme (e.g., clopidogrel, although clinical significance is debated).
## Monitoring
* **Long-term use:** Monitor for magnesium levels, especially in patients taking diuretics or digoxin. Assess bone mineral density in patients at risk for osteoporosis.
* **Patients on concomitant medications:** Be aware of potential drug interactions.
## Clinical Pearls
* Administer pantoprazole 30 minutes before a meal.
* For IV administration, reconstitute and dilute as per manufacturer instructions.
* Long-term PPI use is associated with an increased risk of bone fractures, *C. difficile* infection, hypomagnesemia, and vitamin B12 deficiency. Use the lowest effective dose for the shortest duration necessary.
* Discontinuation may lead to rebound acid hypersecretion. Consider tapering.
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**Disclaimer:** This information is intended for clinical use and does not replace a comprehensive review of the most current prescribing information and professional judgment. Always verify current dosing, indications, contraindications, and warnings with the official product monograph or a trusted drug information resource before initiating therapy.
