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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases gastric acid production.
## Primary Indications
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Reduction of risk of non-steroidal anti-inflammatory drugs (NSAIDs)-induced gastric ulcers in patients at risk for developing these ulcers.
* Pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive esophagitis:** 40 mg once daily for up to 8 weeks. For maintenance, 40 mg once daily.
* **NSAID-induced gastric ulcers:** 40 mg once daily for up to 8 weeks.
* **Pathological hypersecretory conditions:** Starting dose 40 mg twice daily. Doses may be increased as needed. Doses exceeding 80 mg daily should be divided and given twice daily.
## Pediatric Dosing
* **Erosive esophagitis (12 years and older):** 40 mg once daily for up to 8 weeks.
* **GERD symptoms (5 years and older):** 20 mg to 40 mg once daily. Duration of treatment varies.
* **Safety and efficacy for other indications in pediatric patients have not been established.**
## Dose Adjustments
* **Hepatic Impairment:** Maximum daily dose of 40 mg.
* **Renal Impairment:** No dose adjustment recommended.
## 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), hypomagnesemia (can be severe and prolonged), vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Drugs affected by gastric pH:** Absorption may be altered (e.g., ketoconazole, itraconazole, iron salts, vitamin B12).
* **Methotrexate:** May increase and prolong serum levels of methotrexate.
* **CYP2C19 Substrates:** May inhibit CYP2C19, potentially increasing levels of drugs metabolized by this enzyme (e.g., clopidogrel, citalopram, escitalopram). Caution and potential dose adjustments may be needed for these drugs.
## Monitoring
* Electrolytes (magnesium, potassium, calcium) with prolonged use or in patients on concurrent diuretics.
* Vitamin B12 levels with long-term therapy.
* Bone mineral density in patients at risk for osteoporosis.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes before a meal.
* Intravenous (IV) formulation is available for patients who cannot take oral medications. Reconstitution and dilution instructions must be followed carefully for IV administration.
* Long-term PPI use is associated with increased risk of fractures, *C. difficile* infection, and vitamin B12 deficiency. Consider the lowest effective dose for the shortest duration necessary.
* While PPIs are generally safe, consider the potential for drug interactions, especially with drugs like clopidogrel (though clinical significance is debated) and methotrexate.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines before making clinical decisions. Local protocols may dictate specific dosing or management strategies.
