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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
* Gastroesophageal reflux disease (GERD) - healing of erosive esophagitis and maintenance of healing.
* Pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
* Prevention of NSAID-associated gastric ulcers in patients with a history of these ulcers and who are taking NSAIDs.
## Adult Dosing
* **GERD (healing of erosive esophagitis):** 40 mg orally or intravenously once daily for up to 8 weeks.
* **GERD (maintenance of healing):** 40 mg orally once daily. Some patients may be managed on 20 mg orally once daily.
* **Pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome):** Starting dose is typically 40 mg orally or intravenously twice daily. The dose should be titrated based on the degree of acid suppression required. Doses can range up to 240 mg daily.
* **Prevention of NSAID-associated gastric ulcers:** 40 mg orally once daily.
## Pediatric Dosing
* **GERD (healing of erosive esophagitis):**
* **12 to 17 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.
* There is insufficient data for use in pediatric patients under 5 years of age.
## Dose Adjustments
No dose adjustment is typically required for hepatic or renal impairment.
## Contraindications
Known hypersensitivity to pantoprazole or any component of the formulation. Coadministration with rilpivirine-containing products.
## Adverse Effects
Common: Headache, diarrhea, nausea, abdominal pain, dizziness, flatulence.
Serious: *Clostridium difficile*-associated diarrhea, bone fractures (hip, wrist, spine), hypomagnesemia, vitamin B12 deficiency, fundic gland polyps.
## Key Drug Interactions
* **Drugs requiring gastric acid for absorption:** May decrease absorption of drugs like ketoconazole, itraconazole, posaconazole, iron salts, and vitamin B12.
* **CYP2C19 substrates:** Pantoprazole is a moderate inhibitor of CYP2C19. May increase levels of drugs like clopidogrel (though clinical significance is debated and clopidogrel's active metabolite is reduced).
* **Methotrexate:** PPIs may increase methotrexate levels.
* **Rilpivirine:** Contraindicated due to increased risk of virologic failure.
## Monitoring
* Monitor for symptoms of *C. difficile*-associated diarrhea.
* Consider magnesium levels periodically, especially with prolonged use (typically > 1 year) or concomitant use of other drugs that lower magnesium (e.g., diuretics).
* Monitor for signs and symptoms of bone fractures.
* Assess for vitamin B12 deficiency with prolonged therapy.
## Clinical Pearls
* Administer pantoprazole oral suspension or delayed-release tablets 30 minutes before a meal.
* Intravenous administration requires reconstitution and dilution; follow specific preparation guidelines.
* Long-term PPI use is associated with increased risks of adverse events; use the lowest effective dose for the shortest duration necessary.
* If switching from pantoprazole to another PPI, do so carefully to maintain acid suppression.
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*Please verify current prescribing information for the most up-to-date details, including specific dosing guidelines, contraindications, and drug interactions.*
