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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## 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
* **Healing of Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of Healing:** 40 mg orally once daily. May consider 20 mg orally once daily for long-term use.
* **Hypersecretory Conditions:** Starting dose is typically 40 mg orally or intravenously twice daily. Doses may be increased as needed. Maximum recommended dose is 240 mg intravenously daily given in divided doses. Oral doses up to 200 mg daily have been given in divided doses.
## Pediatric Dosing
* **GERD (Erosive Esophagitis):**
* **1 to 5 years:** 10 mg orally once daily for up to 8 weeks.
* **5 to 12 years:** 20 mg orally once daily for up to 8 weeks.
* **12 to 16 years:** 40 mg orally once daily for up to 8 weeks.
* **Note:** Intravenous dosing in pediatric patients is not recommended. Efficacy and safety for indications other than erosive esophagitis are not established in pediatric patients.
## Dose Adjustments
* **Hepatic Impairment:** Reduce the daily dose of pantoprazole to 20 mg orally once daily for long-term treatment of GERD. For other indications, dose adjustments may be necessary based on clinical judgment. Intravenous dose should not exceed 40 mg daily.
* **Renal Impairment:** No dose adjustment is necessary.
## Contraindications
* Known hypersensitivity to pantoprazole, any component of the formulation, or any other substituted benzimidazole.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness.
* **Serious:** Fundic gland polyps (long-term use), *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with prolonged use, hypomagnesemia (long-term use), vitamin B12 deficiency (long-term use), systemic lupus erythematosus.
## Key Drug Interactions
* **Certain Antiretrovirals:** Reduced absorption of drugs like atazanavir and nelfinavir due to increased gastric pH. Separate administration or avoid.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. Consider dose reduction or interruption of pantoprazole.
* **CYP2C19 Substrates:** Pantoprazole can inhibit CYP2C19. Use caution with drugs metabolized by this enzyme (e.g., clopidogrel, citalopram).
* **Iron salts, ketoconazole, itraconazole:** Absorption may be decreased due to increased gastric pH.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., muscle spasms, seizures, tremor, arrhythmias) with prolonged therapy.
* Monitor bone mineral density in patients at risk for osteoporosis.
* Monitor for signs of *C. difficile* infection.
* Monitor for vitamin B12 deficiency with long-term therapy.
## Clinical Pearls
* Intravenous administration is generally reserved for patients who cannot take oral medication.
* Pantoprazole should be taken at least 30 minutes before a meal.
* Long-term use of PPIs is associated with increased risk of fractures, *C. difficile* infection, and hypomagnesemia. The lowest effective dose should be used for the shortest duration necessary.
* Reevaluate the need for continued treatment periodically.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details and to guide patient care.
