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# Pantoprazole ## Overview Pantoprazole is a proton pump inhibitor (PPI) that decreases acid production in the stomach. It is available as oral and intravenous formulations. ## Primary Indications * Gastroesophageal reflux disease (GERD) - healing of erosive esophagitis and maintenance of healing. * Zollinger-Ellison syndrome and other pathological hypersecretory conditions. * Healing of duodenal ulcers. * Prevention of NSAID-induced gastric ulcers in patients at risk. ## Adult Dosing * **GERD/Erosive Esophagitis:** 40 mg orally once daily for 4 to 8 weeks. For maintenance of healing, 20-40 mg once daily. * **Duodenal Ulcer Healing:** 40 mg orally once daily for 4 weeks. * **Zollinger-Ellison Syndrome:** Dosing is individualized. Initiate at 40 mg orally twice daily. Doses may be increased. Maximum dose is 240 mg daily. * **IV Dosing:** For conditions requiring IV administration (e.g., inability to take oral), typically 40 mg IV once daily. For pathological hypersecretory conditions, 80 mg IV every 24 hours. ## Pediatric Dosing Dosing in pediatric patients varies by age and indication. Always refer to specific guidelines. * **GERD/Erosive Esophagitis (12 years and older):** 40 mg orally once daily for up to 8 weeks. * **GERD/Erosive Esophagitis (5-11 years):** 20 mg orally once daily for up to 8 weeks. * Dosing for younger children is less established and should be based on weight and specific indication, often in the range of 0.7 to 1.5 mg/kg/day, not to exceed adult doses. ## Dose Adjustments No dose adjustment is generally required for hepatic or renal impairment, though caution may be advised in severe hepatic impairment. ## Contraindications * Known hypersensitivity to pantoprazole or any component of the formulation. * Concomitant use of rilpivirine. ## Adverse Effects Common: Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness. Less common/Serious: *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia (can be severe), vitamin B12 deficiency, lupus erythematosus, acute interstitial nephritis. ## Key Drug Interactions * **Rilpivirine:** Coadministration is contraindicated due to risk of reduced plasma concentrations of rilpivirine. * **Drugs Dependent on Gastric pH:** May decrease absorption of drugs where gastric pH is important for absorption (e.g., ketoconazole, itraconazole, iron salts, vitamin B12). * **Methotrexate:** PPIs may increase methotrexate levels. Consider holding pantoprazole during methotrexate treatment. * **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. May affect metabolism of drugs like clopidogrel, although clinical significance is debated. ## Monitoring * Monitor for signs and symptoms of *C. difficile*-associated diarrhea. * Monitor electrolytes (magnesium, sodium, potassium) especially with prolonged use or in patients on diuretics. * Assess for bone fracture risk with long-term use. * Monitor B12 levels with prolonged therapy (>3 years). ## Clinical Pearls * Administer oral pantoprazole 30 minutes to 1 hour before a meal. * Oral tablets should be swallowed whole and not chewed, split, or crushed. Delayed-release granules should be sprinkled on applesauce and swallowed immediately without chewing. * IV administration should be over at least 15 minutes. * Long-term PPI use is associated with increased risk of certain adverse events; use the lowest effective dose for the shortest duration necessary. *** *This information is for educational purposes only and does not substitute for professional medical advice. Always verify current prescribing information and guidelines before making clinical decisions.*