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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Erosive esophagitis associated with 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 with antibiotics)
## Adult Dosing
* **Erosive esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks. For maintenance, 40 mg orally once daily.
* **GERD symptom relief:** 20 mg orally once daily. If not controlled, may increase to 40 mg orally once daily.
* **Pathological hypersecretory conditions:** Starting dose is 40 mg orally or intravenously twice daily. Doses may be increased as needed. Maximum recommended dose is 240 mg intravenously daily or 120 mg orally twice daily.
* ***H. pylori* eradication:** 40 mg orally twice daily for 7-14 days in combination with amoxicillin and clarithromycin or clarithromycin and metronidazole.
## Pediatric Dosing
* **Erosive esophagitis (12 to 16 years):** 40 mg orally once daily for up to 8 weeks.
* **GERD symptoms (5 to 16 years):** 20 mg orally once daily. May increase to 40 mg orally once daily if symptoms are not controlled.
* **Erosive esophagitis (2 to 5 years):** 15 mg orally once daily for up to 8 weeks.
* **Erosive esophagitis (2 to 12 years):** 20 mg orally once daily for up to 8 weeks.
*Note: Dosing for pediatric patients < 5 years for erosive esophagitis is based on limited data and should be guided by prescriber judgment and local protocols.*
## Dose Adjustments
* **Hepatic Impairment:** For severe hepatic impairment, the recommended daily dose should not exceed 20 mg orally or 40 mg intravenously every other day.
## Contraindications
* Known hypersensitivity to pantoprazole, any component of the formulation, or other substituted benzimidazoles.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, flatulence, vomiting, dizziness.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, hypomagnesemia, fundic gland polyps, systemic lupus erythematosus, vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** May decrease absorption of drugs such as ketoconazole, itraconazole, posaconazole, erlotinib, and others.
* **Methotrexate:** May increase methotrexate levels.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Use with caution with drugs primarily metabolized by CYP2C19 (e.g., clopidogrel).
* **Atazanavir and nelfinavir:** Concurrent use is not recommended.
## Monitoring
* Electrolyte levels (magnesium, calcium, potassium) with prolonged therapy.
* Bone mineral density in patients at risk for osteoporosis.
* Signs and symptoms of *C. difficile* infection.
* Vitamin B12 levels with long-term therapy.
## Clinical Pearls
* Administer pantoprazole 30 minutes before a meal.
* IV administration should be over 15 minutes.
* Long-term use of PPIs can increase the risk of fractures, C. difficile infection, and hypomagnesemia. Consider the shortest duration of treatment needed to achieve treatment goals.
* Pantoprazole can be administered with antacids.
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*This information is intended for healthcare professionals. Always consult the current prescribing information and institutional protocols before making clinical decisions.*
