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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces the production of stomach acid.
## Primary Indications
* Healing of erosive esophagitis associated with GERD.
* Maintenance of healing of erosive esophagitis.
* Treatment of pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome).
## Adult Dosing
* **Erosive esophagitis healing:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Erosive esophagitis maintenance:** 40 mg orally once daily.
* **Pathological hypersecretory conditions:** Initiate with 40 mg orally or intravenously twice daily. Doses may be increased as needed. Doses exceeding 80 mg daily should be divided and administered twice daily.
## Pediatric Dosing
* **Erosive esophagitis healing (5 to 16 years):** 20 mg orally once daily for up to 8 weeks.
* **Erosive esophagitis healing (1 to <5 years):** 20 mg orally once daily for up to 8 weeks.
* **Erosive esophagitis healing (<1 year):** Dosing not established.
*Note: Dosing for intravenous administration in pediatric patients may vary based on body weight and is often based on local institutional protocols.*
## Dose Adjustments
* **Hepatic Impairment:** Maximum daily oral dose is 20 mg for patients with severe hepatic impairment.
* **Renal Impairment:** No dose adjustment is generally required.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, flatulence.
* **Serious:**
* Long-term use of PPIs (including pantoprazole) may be associated with an increased risk of *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), and vitamin B12 deficiency.
* Acute interstitial nephritis.
* Hypomagnesemia.
* Fundic gland polyps.
## Key Drug Interactions
* **Drugs Dependent on Gastric pH for Absorption:** May decrease absorption of drugs like ketoconazole, itraconazole, posaconazole, iron salts, and vitamin B12.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Caution may be warranted with substrates like clopidogrel, citalopram, and sertraline, though clinical significance is debated.
* **CYP3A4 Substrates:** May inhibit CYP3A4 to a lesser extent.
## Monitoring
* Monitor for signs and symptoms of *Clostridium difficile*-associated diarrhea.
* Consider monitoring serum magnesium levels in patients on long-term therapy, especially if taking concomitant digoxin or diuretics.
* Assess for bone fracture risk factors with prolonged use.
* Monitor for symptoms of vitamin B12 deficiency with prolonged use.
## Clinical Pearls
* Pantoprazole is available in both oral and intravenous formulations. The intravenous formulation should be reconstituted and diluted according to manufacturer instructions.
* For oral administration, pantoprazole tablets should not be crushed or chewed. Delayed-release granules should be mixed with applesauce or apple juice and swallowed immediately.
* Consider the lowest effective dose for the shortest duration necessary to manage the condition.
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*Disclaimer: This information is intended for clinical decision-making and does not replace comprehensive drug information resources. Always consult the official prescribing information and institutional protocols for the most current and complete details.*
