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# Pantoprazole
## Overview
Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion.
## Primary Indications
* Gastroesophageal reflux disease (GERD) - symptomatic relief and healing of erosive esophagitis.
* Zollinger-Ellison syndrome.
* Part of *Helicobacter pylori* eradication regimens.
## Adult Dosing
* **GERD/Erosive Esophagitis:**
* Oral: 20 mg once daily for up to 8 weeks.
* IV: 40 mg once daily.
* **Maintenance of Healing Erosive Esophagitis:**
* Oral: 20 mg once daily.
* **Zollinger-Ellison Syndrome:**
* Oral: Starting dose 40 mg once daily, may increase to 240 mg daily divided into doses (maximum daily dose is typically limited by tolerability and efficacy, with doses up to 220 mg BID reported).
* IV: Starting dose 80 mg once daily, may increase to 160 mg daily divided into 2 doses.
* ***H. pylori* Eradication (in combination therapy):**
* Oral: 40 mg twice daily for 7-14 days.
## Pediatric Dosing
* **GERD/Erosive Esophagitis:**
* Ages 5 to 11 years:
* Oral: 20 mg once daily for up to 8 weeks.
* Ages 12 to 16 years:
* Oral: 20 mg once daily for up to 8 weeks.
*Note: Dosing for children under 5 years is not well-established and should be based on expert opinion or institutional protocols.*
## Dose Adjustments
* **Hepatic Impairment:** Maximum daily dose of 40 mg oral or 40 mg IV.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* Known hypersensitivity to pantoprazole or any component of the formulation.
* Concurrent use with rilpivirine.
## Adverse Effects
Common: Headache, diarrhea, nausea, dizziness, abdominal pain, flatulence.
Less Common/Serious: *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with long-term use, hypomagnesemia, vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** Ketoconazole, itraconazole, iron salts, vitamin B12. PPIs decrease absorption.
* **CYP2C19 substrates:** Such as clopidogrel. Pantoprazole may increase clopidogrel levels.
* **Methotrexate:** PPIs may increase methotrexate levels.
* **Rilpivirine:** Contraindicated due to risk of decreased rilpivirine plasma concentrations.
* **Sucralfate:** May decrease absorption of pantoprazole; separate administration by at least 30 minutes.
## Monitoring
* Monitor for signs and symptoms of *C. difficile*-associated diarrhea.
* Consider monitoring magnesium levels, especially with prolonged use (>1 year) or concomitant use of diuretics or digoxin.
* Evaluate for bone fracture risk with long-term therapy.
* Monitor for symptoms of B12 deficiency with prolonged use.
## Clinical Pearls
* Administer oral pantoprazole at least 30 minutes before a meal for optimal efficacy.
* IV pantoprazole should be administered as a slow infusion over 15 minutes or as a bolus injection over 2 minutes.
* Duration of therapy for GERD should generally not exceed 8 weeks unless clinically indicated.
* Long-term PPI use is associated with increased risk of fractures, *C. difficile* infection, and vitamin B12 deficiency. Use the lowest effective dose for the shortest duration necessary.
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*Disclaimer: This information is intended for clinical use and does not replace professional judgment. Always verify current prescribing information with the official product monograph or other authoritative sources before making clinical decisions.*
