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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.
* Treatment of pathological hypersecretory conditions, such as Zollinger-Ellison syndrome.
## Adult Dosing
* **Healing of Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of Healing:** 40 mg orally once daily. Some patients may be treated with 20 mg orally once daily.
* **Pathological Hypersecretory Conditions:** Starting dose is typically 40 mg orally or intravenously twice daily. Doses may be adjusted based on individual need and may range from 40 mg to up to 240 mg intravenously per day divided into infusions.
## Pediatric Dosing
* **GERD (erosive esophagitis):**
* **12 to 16 years:** 40 mg orally once daily for up to 8 weeks.
* **5 to 11 years:** 20 mg orally once daily for up to 8 weeks. Doses higher than 20 mg daily have not been studied in children younger than 12 years.
* **Note:** Dosing for younger pediatric patients or other indications in pediatrics is less established and should be based on specialist recommendations and available literature.
## Dose Adjustments
* **Hepatic Impairment:** Maximum daily dose is 40 mg orally or intravenously once daily.
* **Renal Impairment:** No dose adjustment needed.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of its formulation.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, flatulence.
* **Serious:** Clostridium difficile-associated diarrhea, bone fracture (hip, wrist, spine), hypomagnesemia (can be severe, potentially leading to arrhythmias, seizures, and tetany), vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Absorption may be decreased (e.g., ketoconazole, itraconazole, posaconazole, iron salts, vitamin B12). Separate administration or consider alternative therapies.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. Consider interactions with drugs like clopidogrel, though clinical significance can vary.
## Monitoring
* Electrolytes (especially magnesium and sodium) with prolonged therapy.
* Bone mineral density with long-term use.
* Signs and symptoms of C. difficile infection.
* Vitamin B12 levels with prolonged therapy.
## Clinical Pearls
* Pantoprazole is generally considered to have fewer CYP2C19-mediated drug interactions compared to omeprazole and esomeprazole, which may be advantageous in patients on clopidogrel.
* IV formulation requires reconstitution and dilution; follow specific manufacturer instructions.
* Long-term PPI use is associated with increased risk of fractures, C. difficile infection, and hypomagnesemia. Regularly reassess the need for continued therapy.
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*Please verify this information with the most current prescribing information or a trusted clinical resource before making any clinical decisions.*
