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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production.
## 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 healing:** 40 mg orally once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose is typically 40 mg orally twice daily, with potential titration up to 240 mg orally daily divided into doses.
## Pediatric Dosing
* **Erosive esophagitis (ages 5 to 16 years):** 20 mg orally once daily for up to 8 weeks. Higher doses may be used under specialist guidance.
* **GERD symptoms (ages 5 to 16 years):** 20 mg orally once daily.
## Dose Adjustments
No specific dose adjustments are routinely recommended for renal impairment. In severe hepatic impairment, a dose of 20 mg orally once daily is recommended.
## Contraindications
Known hypersensitivity to pantoprazole or any component of its formulation.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, and dizziness. Long-term use of PPIs may be associated with an increased risk of *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** PPIs can decrease absorption of drugs like ketoconazole, itraconazole, and certain HIV protease inhibitors (e.g., atazanavir).
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Consider potential interactions with drugs metabolized by this enzyme (e.g., clopidogrel, voriconazole).
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremors, seizures, muscle cramps).
* Assess for potential *C. difficile* infection, especially with prolonged therapy or antibiotic use.
* Consider monitoring vitamin B12 levels with long-term therapy.
## Clinical Pearls
* Administer oral pantoprazole at least 30 minutes before a meal.
* For patients unable to swallow intact tablets, pantoprazole delayed-release tablets can be dispersed in 10 mL of water or 10.2 mL of applesauce.
* IV formulations are available for patients unable to take oral medication. Standard IV dose is 40 mg daily.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols for definitive guidance. Local protocols may dictate specific dosing strategies, especially for complex indications or specific patient populations.*
