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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Erosive esophagitis associated with gastroesophageal reflux disease (GERD)
* Healing of erosive esophagitis
* Pathological hypersecretory conditions, such as Zollinger-Ellison syndrome
## Adult Dosing
* **Healing of Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of Healing:** 40 mg orally once daily.
* **GERD (symptomatic):** 20 mg orally once daily for up to 4 weeks.
* **Zollinger-Ellison Syndrome:** 40 mg orally or intravenously once daily, may be increased to 80 mg intravenously or orally once daily. The maximum recommended dose is 80 mg every 12 hours.
## Pediatric Dosing
* **Erosive Esophagitis (age 5 to 16 years):** 20 mg or 40 mg orally once daily for up to 8 weeks. Dosing based on weight and severity.
* **GERD (age 5 to 16 years):** 20 mg orally once daily for up to 4 weeks.
* **Note:** Specific pediatric dosing can be complex and may require specialist consultation.
## Dose Adjustments
* **Hepatic Impairment:** Maximum dose of 40 mg orally daily. No dose adjustment necessary for IV administration.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Use of rilpivirine-containing products.
## Adverse Effects
* **Common:** Diarrhea, headache, nausea, abdominal pain, dizziness, flatulence.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term, high-dose use, hypomagnesemia (can be severe, may lead to hypocalcemia and hypokalemia), lupus erythematosus (cutaneous and systemic), vitamin B12 deficiency.
## Key Drug Interactions
* **CYP2C19 Substrates:** May increase plasma concentrations of drugs metabolized by CYP2C19 (e.g., clopidogrel, voriconazole, citalopram, sertraline).
* **CYP3A4 Substrates:** May increase concentrations of drugs metabolized by CYP3A4 (e.g., ketoconazole, itraconazole).
* **Methotrexate:** May increase methotrexate levels.
* **Rilpivirine:** Contraindicated due to risk of virologic failure.
* **Iron Salts, Antifungals (azoles):** Absorption may be decreased due to reduced gastric acidity.
* **Sucralfate:** May decrease absorption; separate administration by at least 30 minutes.
## Monitoring
* Monitor for signs and symptoms of *C. difficile*-associated diarrhea.
* Monitor serum magnesium levels periodically, especially with prolonged use (>1 year) or concomitant diuretic use.
* Monitor for signs and symptoms of bone fracture risk.
* Monitor for signs and symptoms of vitamin B12 deficiency with prolonged therapy.
* Monitor for signs of cutaneous or systemic lupus erythematosus.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes before a meal.
* For IV administration, reconstitution and further dilution are required.
* Long-term PPI use is associated with an increased risk of fractures, *C. difficile* infection, and vitamin B12 deficiency. Consider the lowest effective dose for the shortest duration necessary.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before making therapeutic decisions.*
