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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces 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, including Zollinger-Ellison syndrome.
## Adult Dosing
* **Erosive esophagitis healing:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of healing:** 40 mg orally once daily. May consider 20 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose typically 40 mg orally or intravenously twice daily. Doses can be titrated upwards as needed. Usual dose range is 40 mg to 80 mg daily, divided into doses. Maximum dose typically 80 mg intravenously every 12 hours or 160 mg intravenously every 24 hours.
## Pediatric Dosing
* **Erosive esophagitis healing (ages 5-16 years):** 20 mg or 40 mg orally once daily for up to 4 weeks.
* **Pathological hypersecretory conditions:** Dosing is not well-established in pediatrics. Consult specialized pediatric literature or guidelines.
## Dose Adjustments
No dose adjustment is typically needed 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 the formulation.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, dizziness, and flatulence. Long-term use may be associated with increased risk of *Clostridium difficile* infection, bone fractures (hip, wrist, spine), hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Clopidogrel:** Pantoprazole may decrease the efficacy of clopidogrel. Avoid concurrent use if possible, or consider alternative PPIs if clopidogrel is essential.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. Consider temporary PPI discontinuation during high-dose methotrexate therapy.
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, and certain HIV medications (e.g., atazanavir, nelfinavir) may have reduced absorption.
## Monitoring
* Monitor for signs and symptoms of hypomagnesemia (e.g., tremors, seizures, arrhythmias) particularly with prolonged use (≥ 3 months) or concomitant diuretic use.
* Monitor for signs of fracture risk with long-term use.
* Monitor for signs of *Clostridium difficile* infection.
* Consider monitoring magnesium levels in patients at risk or on long-term therapy.
## Clinical Pearls
* Administer oral pantoprazole 30 minutes to 1 hour before a meal.
* IV administration is for patients who cannot take oral medication.
* IV infusion should be over 15 minutes. IV bolus should be over 2 minutes.
* Consider the risks of long-term PPI use versus the benefits of acid suppression.
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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 dosing and safety information before initiating therapy.
