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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Gastroesophageal reflux disease (GERD)
* Erosive esophagitis
* Zollinger-Ellison syndrome
* Healing of duodenal ulcers
* H. pylori eradication (in combination with antibiotics)
## Adult Dosing
* **GERD/Erosive Esophagitis:** 40 mg orally or IV once daily. Duration of therapy varies.
* **Zollinger-Ellison Syndrome:** Starting dose typically 40 mg orally or IV twice daily. Doses adjusted based on gastric acid output. Maximum recommended dose is 240 mg/day.
* **H. pylori Eradication:** 40 mg orally twice daily in combination with two antibiotics for 7-14 days.
## Pediatric Dosing
* **GERD:**
* **1 month to <5 years:** 1.1 mg/kg/day orally once daily. Maximum 20 mg/day.
* **5 years to <17 years:** 20 mg orally once daily. For more severe esophagitis, 40 mg orally once daily.
## Dose Adjustments
* **Hepatic Impairment:** Oral formulation: Maximum dose 20 mg once daily. IV formulation: Dose adjustment may be needed, consult prescribing information.
* **Renal Impairment:** No dose adjustment is generally required.
## Contraindications
* Known hypersensitivity to pantoprazole or other benzimidazole derivatives.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
* **Serious:** *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia (can be serious, may lead to cardiac arrhythmias, seizures), vitamin B12 deficiency (with prolonged use), fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, posaconazole, iron salts, vitamin B12. Pantoprazole can decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 Substrates/Inhibitors:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution with clopidogrel.
* **Antiretrovirals:** May alter absorption of certain antiretroviral drugs.
## Monitoring
* **Long-term use (>1 year):** Monitor for vitamin B12 deficiency and hypomagnesemia. Consider periodic serum magnesium levels.
* **Bone fractures:** Assess risk factors and consider bone mineral density monitoring if indicated.
## Clinical Pearls
* Administer oral pantoprazole 30-60 minutes before a meal.
* IV administration requires reconstitution and dilution.
* Oral disintegrating tablets should be placed on the tongue and swallowed; do not chew or crush.
* The risk of *C. difficile* infection increases with PPI use.
* Long-term PPI use is associated with increased risk of gastric cancer, although the clinical significance is debated.
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This information is intended for clinical use and does not replace comprehensive drug information resources. Always verify current prescribing information before initiating therapy.
