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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Gastroesophageal reflux disease (GERD) - erosive esophagitis
* Healing of erosive esophagitis
* Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
* Duodenal ulcers
* Gastric ulcers
## Adult Dosing
* **Healing of Erosive Esophagitis:** 40 mg orally or intravenously once daily for up to 8 weeks.
* **Maintenance of Healing of Erosive Esophagitis:** 40 mg orally once daily. May be given 20 mg orally once daily if clinically indicated.
* **GERD (symptomatic relief):** 20 mg to 40 mg orally once daily.
* **Pathological Hypersecretory Conditions:** Starting dose is typically 40 mg orally or intravenously twice daily. Doses may be increased to 240 mg daily given as 40 mg to 80 mg every 6-8 hours.
* **Duodenal Ulcers:** 40 mg orally once daily for up to 4 weeks.
* **Gastric Ulcers:** 40 mg orally once daily for 4 to 8 weeks.
* **Intravenous (IV):** For patients who cannot take oral medication, the dose is typically 40 mg IV once daily. For pathological hypersecretory conditions, IV doses can be higher and more frequent.
## Pediatric Dosing
Dosing in pediatric patients is less established and should be based on specific indications and weight.
* **GERD (erosive esophagitis):**
* **1 to 5 years:** 10 mg to 20 mg orally once daily.
* **5 to 12 years:** 20 mg orally once daily.
* **12 years and older:** 40 mg orally once daily.
* **Note:** Dosing for pediatric patients with pathological hypersecretory conditions is not well-established.
## Dose Adjustments
* **Hepatic Impairment:** Maximum daily dose of 40 mg orally or IV once daily in patients with severe hepatic impairment.
* **Renal Impairment:** No dose adjustment is typically required.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Use of rilpivirine-containing products.
## Adverse Effects
Common adverse effects include diarrhea, headache, dizziness, abdominal pain, nausea, and flatulence. Long-term use may be associated with an increased risk of *Clostridium difficile*-associated diarrhea, bone fractures, hypomagnesemia, and vitamin B12 deficiency.
## Key Drug Interactions
* **Drugs Dependent on Gastric pH for Absorption:** PPIs can alter gastric pH, affecting the absorption of drugs like ketoconazole, itraconazole, posaconazole, iron salts, and certain antiretrovirals (e.g., rilpivirine, atazanavir).
* **Methotrexate:** PPIs may increase levels of methotrexate.
* **CYP2C19 Substrates:** Pantoprazole is a moderate inhibitor of CYP2C19 and may increase concentrations of drugs metabolized by this enzyme (e.g., clopidogrel, although clinical significance is debated).
## Monitoring
* Monitor for signs and symptoms of *Clostridium difficile* infection.
* Monitor serum magnesium levels periodically, especially with prolonged use or concomitant diuretic use.
* Monitor for signs of vitamin B12 deficiency with prolonged therapy.
* Assess for bone fracture risk in patients with risk factors.
## Clinical Pearls
* Pantoprazole is generally considered less likely to interact with clopidogrel compared to omeprazole and esomeprazole due to weaker CYP2C19 inhibition.
* For IV administration, reconstitute and further dilute as per manufacturer instructions.
* Do not crush or chew delayed-release oral formulations.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the official prescribing information and current guidelines for the most up-to-date and complete drug information.*
