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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
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily. Some patients may be treated with 20 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose is typically 40 mg orally or intravenously twice daily. Doses may be increased to 40 mg up to three times daily. Doses as high as 240 mg intravenously daily have been administered.
## Pediatric Dosing
* **Erosive esophagitis (ages 5 to 16 years):** 40 mg orally once daily for up to 8 weeks.
* **GERD (ages 5 to 16 years):** 20 mg to 40 mg orally once daily for up to 8 weeks.
* Dosing for children younger than 5 years is not established.
## Dose Adjustments
* **Hepatic impairment:** Maximum dose is 40 mg orally or intravenously once daily.
* **Renal impairment:** No dose adjustment is generally needed.
## 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 fracture (hip, wrist, spine) with long-term use, hypomagnesemia (especially with prolonged use), Vitamin B12 deficiency with prolonged use, potential for fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric pH for absorption:** Absorption may be decreased by pantoprazole (e.g., ketoconazole, itraconazole, iron salts, vitamin B12).
* **Methotrexate:** PPIs may increase methotrexate levels; consider temporarily discontinuing pantoprazole if high-dose methotrexate is used.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19; potential for increased levels of drugs metabolized by this enzyme (e.g., clopidogrel - though clinical significance is debated, citalopram, diazepam).
## Monitoring
* Electrolytes (magnesium, calcium, potassium) with long-term therapy.
* Bone mineral density for patients at risk of osteoporosis with long-term therapy.
* Clinical signs and symptoms of B12 deficiency.
* Stool for C. difficile if diarrhea develops.
## Clinical Pearls
* Administer oral pantoprazole at least 30 minutes before a meal.
* Intravenous infusion should be administered over at least 15 minutes.
* Long-term use of PPIs is associated with increased risks, including fractures, C. difficile infection, and hypomagnesemia. Use the lowest effective dose for the shortest duration necessary.
* Consider switching from IV to PO formulation when clinically appropriate.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols for complete details.*
