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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that decreases the amount of acid produced in the stomach.
## Primary Indications
* Healing of erosive esophagitis
* Maintenance of healing of erosive esophagitis
* Symptomatic gastroesophageal reflux disease (GERD)
* Dose for H. pylori eradication (in combination therapy)
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally once daily for 4 to 8 weeks.
* **Maintenance of healing erosive esophagitis:** 40 mg orally once daily.
* **Symptomatic GERD:** 20 mg orally once daily for up to 4 weeks.
* **H. pylori eradication:** 40 mg orally twice daily for 7 days, in combination with amoxicillin 1000 mg orally twice daily and clarithromycin 500 mg orally twice daily.
* **Pathological hypersecretory conditions:** Starting dose is 40 mg orally twice daily. Doses may be increased as clinically needed. Doses up to 240 mg daily have been administered intravenously.
## Pediatric Dosing
* **Erosive esophagitis (ages 5 to 16 years):** 40 mg orally once daily for 4 to 8 weeks.
* **Symptomatic GERD (ages 5 to 16 years):** 20 mg orally once daily for up to 4 weeks.
* **Safety and efficacy in younger pediatric patients are not established.**
## Dose Adjustments
* **Hepatic impairment:** Maximum dose of 40 mg once daily.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of its 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, potentially leading to neuromuscular and cardiac complications), vitamin B12 deficiency (long-term use), systemic lupus erythematosus.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, iron salts, ampicillin esters, erlotinib, nelfinavir. Pantoprazole can decrease absorption.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. May affect metabolism of drugs like clopidogrel.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., muscle cramps, tremors, seizures, arrhythmias).
* Monitor for signs of vitamin B12 deficiency with long-term therapy.
* Consider monitoring bone mineral density in patients at risk for osteoporosis.
* Assess for C. difficile infection if diarrhea develops.
## Clinical Pearls
* Pantoprazole is generally administered 30-60 minutes before a meal.
* IV to PO conversion should be based on patient's condition and oral availability.
* Long-term use of PPIs is associated with increased risk of fractures, C. difficile infection, and hypomagnesemia. Consider risks and benefits with prolonged therapy.
**Disclaimer:** This information is intended for clinical professionals. Always verify current prescribing information and consult with a healthcare provider for patient-specific recommendations.
