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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, such as Zollinger-Ellison syndrome. ## Adult Dosing * **Erosive esophagitis:** 40 mg orally once daily for up to 8 weeks. * **Maintenance of healing:** 40 mg orally once daily. * **Pathological hypersecretory conditions:** Starting dose 40 mg orally twice daily, may be increased as clinically needed. Doses up to 240 mg daily have been administered intravenously. Maximum oral dose not established but typically does not exceed 40 mg twice daily for routine indications. ## Pediatric Dosing * **12 years and older:** * **Erosive esophagitis:** 40 mg orally once daily for up to 8 weeks. * **Maintenance of healing:** 40 mg orally once daily. * **Less than 12 years:** Dosing is not established for all indications and formulations. Consult specific pediatric guidelines for further information. ## Dose Adjustments * **Hepatic Impairment:** Reduce the daily dose to 20 mg once daily. * **Renal Impairment:** No dose adjustment is generally necessary. ## Contraindications * Known hypersensitivity to pantoprazole, any component of the formulation, or other substituted benzimidazoles. ## Adverse Effects * **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence. * **Serious:** Vitamin B12 deficiency (long-term use), hypomagnesemia (long-term use), Clostridium difficile-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, lupus erythematosus (cutaneous and systemic). ## Key Drug Interactions * **Drugs requiring gastric acid for absorption:** May decrease absorption of drugs such as ketoconazole, itraconazole, posaconazole, iron salts, and vitamin B12. * **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. * **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Consider potential interactions with drugs like clopidogrel (though clinical significance is debated). ## Monitoring * Monitor for signs and symptoms of hypomagnesemia (e.g., tetany, seizures, tremors, cardiac arrhythmias). * Monitor for signs and symptoms of vitamin B12 deficiency with prolonged therapy. * Monitor bone mineral density in patients at risk for osteoporosis. * Monitor for C. difficile infection. ## Clinical Pearls * Pantoprazole is generally administered 30-60 minutes before a meal. * Do not crush or chew delayed-release formulations. * Long-term PPI use is associated with increased risks of fractures, C. difficile infection, and hypomagnesemia. Consider the lowest effective dose and shortest duration necessary. *** *Please verify current prescribing information for the most up-to-date recommendations.*