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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.
* Reduction of risk of NSAID-associated gastric ulcers in patients with a history of such ulcers who are taking NSAIDs.
* 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.
* **Prevention of Gastric Ulcers (NSAID-induced):** 40 mg orally once daily.
* **Pathological Hypersecretory Conditions:** Starting dose is 40 mg orally or intravenously twice daily. Doses may be increased as clinically warranted. Typical doses range from 40 mg to 120 mg daily, divided every 12 hours. Maximum IV dose is 90 mg every 24 hours.
## Pediatric Dosing
* **Erosive Esophagitis (GERD-associated):**
* **1 to 5 years:** 10 mg orally once daily for up to 8 weeks.
* **5 to 12 years:** 20 mg orally once daily for up to 8 weeks.
* **12 to 17 years:** 40 mg orally once daily for up to 8 weeks.
* **Note:** Intravenous formulations are not recommended for children. Data on long-term safety and efficacy in pediatric patients is limited.
## Dose Adjustments
* **Hepatic Impairment:** For severe hepatic impairment, consider 20 mg orally once daily.
* **Renal Impairment:** No dosage adjustment is generally required.
## Contraindications
* Known hypersensitivity to pantoprazole, any component of the formulation, or other substituted benzimidazoles.
## Adverse Effects
* **Common:** Headache, diarrhea, nausea, abdominal pain, vomiting, dizziness, flatulence.
* **Serious:** *Clostridioides difficile*-associated diarrhea, bone fractures (hip, wrist, spine) with prolonged use, hypomagnesemia, vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Drugs Dependent on Gastric pH for Absorption:** May decrease absorption of drugs such as ketoconazole, itraconazole, posaconazole, iron salts, and vitamin B12.
* **Methotrexate:** PPIs may increase levels of methotrexate.
* **CYP2C19 Substrates:** May inhibit CYP2C19, potentially affecting metabolism of drugs like clopidogrel, citalopram, and diazepam.
## Monitoring
* Monitor for signs and symptoms of *C. difficile*-associated diarrhea.
* Consider monitoring serum magnesium levels, especially with prolonged therapy (typically >1 year) or in patients taking concomitant medications such as digoxin or diuretics.
* Monitor for signs and symptoms of vitamin B12 deficiency with long-term use.
* Bone mineral density assessment may be considered in patients at risk for osteoporosis.
## Clinical Pearls
* Oral pantoprazole is generally preferred over IV for step-down therapy when clinically appropriate.
* IV pantoprazole is typically administered as a continuous infusion in critically ill patients or for those unable to take oral medications. Specific infusion protocols may vary by institution.
* The risk of fracture increases with higher doses and longer duration of therapy. Counsel patients on the lowest effective dose and shortest duration necessary.
* Long-term PPI use can mask symptoms of serious underlying conditions.
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*This information is intended for healthcare professionals and does not substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines before making treatment decisions.*
