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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
* Gastroesophageal reflux disease (GERD)
* Healing of erosive esophagitis
* Treatment of *Helicobacter pylori* infection (in combination with antibiotics)
* Zollinger-Ellison syndrome
## Adult Dosing
* **GERD & Erosive Esophagitis:** 40 mg orally or intravenously once daily. May be increased to 80 mg once daily for short-term management of severe erosive esophagitis.
* ***H. pylori* Eradication:** 40 mg orally twice daily for 7-14 days in combination with amoxicillin 1000 mg orally twice daily and clarithromycin 500 mg orally twice daily.
* **Zollinger-Ellison Syndrome:** Starting dose 40 mg orally or intravenously once daily, titrate as needed. Doses up to 240 mg daily have been administered. Doses >80 mg daily should be divided.
## Pediatric Dosing
* **GERD & Erosive Esophagitis:**
* **1-5 years (15 kg to <25 kg):** 20 mg orally once daily.
* **6-11 years (25 kg to <40 kg):** 20 mg orally once daily.
* **≥12 years:** 40 mg orally once daily.
* **Erosive Esophagitis:**
* **≥5 years:** 40 mg orally once daily.
* *Note: Dosing in pediatric patients should be based on weight. The maximum dose is generally 40 mg once daily unless treating Zollinger-Ellison syndrome.*
## Dose Adjustments
* **Hepatic Impairment:** Maximum dose of 20 mg orally or 40 mg intravenously once daily for patients with severe hepatic impairment.
## Contraindications
* Known hypersensitivity to pantoprazole, any component of the formulation, or other benzimidazole derivatives.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, dizziness, abdominal pain, flatulence.
* **Serious:** *Clostridium difficile*-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia (can be asymptomatic or symptomatic), vitamin B12 deficiency, systemic lupus erythematosus.
## Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** May decrease absorption of drugs like ketoconazole, itraconazole, iron salts, and cyanocobalamin.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. Consider interruption of pantoprazole.
* **CYP2C19 substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs like clopidogrel, although clinical significance is debated.
## Monitoring
* Electrolyte levels (especially magnesium) with prolonged use.
* Bone mineral density with long-term therapy.
* Signs and symptoms of *C. difficile* infection.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes before a meal.
* Do not crush or chew delayed-release tablets; swallow whole.
* Intravenous formulation should be administered as an infusion over 15 minutes.
* Long-term use of PPIs is associated with increased risk of fractures, *C. difficile* infection, and vitamin B12 deficiency.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details and to verify dosages before administration.
