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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
* Healing of erosive esophagitis associated with gastroesophageal reflux disease (GERD).
* Maintenance of healing of erosive esophagitis.
* Reduction of risk for NSAID-associated gastric ulcers in patients with a history of such ulcers who are taking NSAIDs.
* Pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks. For maintenance, 40 mg orally once daily.
* **NSAID-Associated Gastric Ulcers:** 40 mg orally once daily for up to 8 weeks.
* **Zollinger-Ellison Syndrome:** Starting dose typically 40 mg orally twice daily, may be titrated up to 240 mg daily (divided into two doses).
## Pediatric Dosing
* **Erosive Esophagitis (12 years and older):** 40 mg orally once daily for up to 8 weeks.
*There is limited data for use in pediatric patients younger than 12 years.*
## Dose Adjustments
No dose adjustment is generally required for patients with hepatic or renal impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, dizziness, abdominal pain, flatulence.
* **Serious:** Severe hypersensitivity reactions, Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine) with long-term use, hypomagnesemia, vitamin B12 deficiency, potential for fundic gland polyps.
## Key Drug Interactions
* **Drugs dependent on gastric pH for absorption:** Absorption may be affected (e.g., ketoconazole, itraconazole, atazanavir, nelfinavir, iron salts).
* **Methotrexate:** PPIs may increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs metabolized by this enzyme (e.g., clopidogrel, though clinical significance is debated).
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremor, tetany, seizures, arrhythmias).
* Monitor for signs of C. difficile infection.
* Consider baseline and periodic monitoring of magnesium levels in patients on long-term therapy, especially those on concomitant medications like digoxin or diuretics.
* Long-term use may warrant monitoring for vitamin B12 deficiency.
## Clinical Pearls
* Administer pantoprazole orally 30 minutes before a meal.
* If using the delayed-release tablets, instruct patients to swallow them whole and not to crush or chew them.
* For intravenous administration, reconstitute and further dilute according to manufacturer instructions.
* The risk of bone fractures, C. difficile infection, and hypomagnesemia increases with duration of use. Consider discontinuing or reducing the dose when clinically appropriate.
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*Always verify current prescribing information and local protocols.*
