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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid production.
## Primary Indications
* Erosive esophagitis associated with gastroesophageal reflux disease (GERD)
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
* Healing of duodenal ulcers
* Maintenance of healing of erosive esophagitis and duodenal ulcers
* H. pylori eradication (in combination therapy)
## Adult Dosing
* **Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks. A course of up to 16 weeks may be needed for healing.
* **Maintenance of Healing of Erosive Esophagitis:** 40 mg orally once daily.
* **Duodenal Ulcers:** 40 mg orally once daily for 7-14 days.
* **Pathological Hypersecretory Conditions:** Starting dose 40 mg orally or intravenously twice daily. Doses may be increased up to 240 mg daily divided into doses.
* **H. pylori Eradication:** 40 mg orally twice daily for 7-14 days in combination with antibiotics.
## Pediatric Dosing
* **12 years and older:**
* **Erosive Esophagitis:** 40 mg orally once daily for up to 8 weeks.
* **5 years to 11 years:**
* **Erosive Esophagitis:** 20-40 mg orally once daily for up to 8 weeks. Dosing depends on weight: 20 mg for patients weighing 15 kg to < 40 kg; 40 mg for patients weighing ≥ 40 kg.
* **Dosing for younger children and other indications in pediatrics is not well established.**
## Dose Adjustments
No specific dose adjustments are recommended for patients with hepatic or renal impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
* **Serious (long-term use):** Increased risk of *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency.
## Key Drug Interactions
* **Antiretrovirals (e.g., ritonavir, atazanavir):** May decrease absorption and efficacy. Avoid concurrent use or monitor closely.
* **Methotrexate:** PPIs may increase methotrexate levels; consider temporary discontinuation of pantoprazole.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Monitor for potential drug interactions with substrates like clopidogrel, though clinical significance is debated.
* **Iron Supplements, Antifungals (ketoconazole, itraconazole):** Gastric acid reduction can decrease absorption.
## Monitoring
* **Magnesium levels:** Especially in patients on long-term therapy (longer than 3 months, and particularly for more than a year).
* **Vitamin B12 levels:** Consider monitoring in patients on long-term therapy.
* **Bone mineral density:** Consider monitoring in patients with risk factors for osteoporosis.
## Clinical Pearls
* Administer 30-60 minutes before a meal.
* IV formulation should be reconstituted and further diluted before administration.
* Do not crush or chew delayed-release tablets.
* Long-term use should be reserved for patients requiring ongoing treatment and regularly reassessed for ongoing need.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions.
