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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses 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 (e.g., Zollinger-Ellison syndrome).
* H. pylori eradication (in combination with antibiotics).
## 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. May consider 20 mg orally once daily.
* **Pathological hypersecretory conditions:** Start with 40 mg orally or intravenously once daily. Doses may be increased up to 240 mg intravenously or 120 mg orally per day, divided every 8 hours.
* **H. pylori eradication:** 40 mg orally twice daily in combination with clarithromycin and amoxicillin for 7-14 days.
## Pediatric Dosing
* **GERD (erosive esophagitis):**
* 1-5 years: 10 mg orally once daily for up to 8 weeks.
* 5-12 years: 20 mg orally once daily for up to 8 weeks.
* 12-16 years: 40 mg orally once daily for up to 8 weeks.
* **GERD (symptomatic):**
* 1-11 years: 10-20 mg orally once daily.
* 12-16 years: 20 mg orally once daily.
Dosing for other indications in pediatric patients may not be well-established.
## Dose Adjustments
No dose adjustment is generally required for renal impairment. Dose reduction may be considered in severe hepatic impairment.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Concomitant use with rilpivirine.
## Adverse Effects
Common: Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
Less Common: Rash, pruritus, muscle pain, fatigue, insomnia.
## Key Drug Interactions
* **Rilpivirine:** Increased risk of virologic failure. Contraindicated.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity.
* **Drugs dependent on gastric pH for absorption:** Clopidogrel, ketoconazole, itraconazole, iron salts, cyanocobalamin, mycophenolate mofetil.
* **CYP2C19 substrates:** Warfarin, diazepam, phenytoin.
## Monitoring
* Monitor for efficacy (relief of GERD symptoms, healing of esophagitis).
* Monitor for potential adverse effects, especially with long-term use (e.g., bone fractures, C. difficile infection, hypomagnesemia, vitamin B12 deficiency).
## Clinical Pearls
* For IV administration, reconstitute and dilute further; do not administer as a bolus.
* Long-term use of PPIs is associated with an increased risk of fractures (hip, wrist, spine), C. difficile infection, hypomagnesemia, and vitamin B12 deficiency. Consider the risks and benefits, especially in elderly patients or those with other risk factors.
* For H. pylori eradication, ensure compliance with the full antibiotic regimen.
* The 20 mg dose is available for patients requiring lower acid suppression for maintenance therapy.
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*Please verify this information with the most current prescribing information or local institutional guidelines.*
