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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 GERD
* Maintenance of healing of erosive esophagitis
* Treatment of pathological hypersecretory conditions (e.g., 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.
* **Pathological hypersecretory conditions:** 40 mg orally or intravenously twice daily. Doses can be increased as needed. Doses up to 240 mg daily have been administered intravenously.
## Pediatric Dosing
* **Erosive esophagitis (ages 5 to 16 years):** 20 mg or 40 mg orally once daily based on weight (20 mg for <40 kg, 40 mg for ≥40 kg). Duration typically 8 weeks.
* **Erosive esophagitis (ages 1 month to <5 years):** Dosing is weight-based and individualized, often starting at 0.5 mg/kg/day to 1.5 mg/kg/day orally once daily. Limited data available.
## Dose Adjustments
No dose adjustment is necessary for renal impairment. In hepatic impairment, consider a dose reduction to 20 mg orally once daily.
## Contraindications
Hypersensitivity to pantoprazole or any component of the formulation. Concomitant use with rilpivirine.
## Adverse Effects
Common adverse effects include headache, diarrhea, nausea, abdominal pain, dizziness, and flatulence. Long-term use may be associated with an increased risk of C. difficile infection, bone fractures (hip, wrist, spine), vitamin B12 deficiency, and hypomagnesemia.
## Key Drug Interactions
* **Rilpivirine:** Pantoprazole decreases rilpivirine concentrations, leading to loss of virologic response and potential resistance. Avoid coadministration.
* **Methotrexate:** PPIs may increase methotrexate levels, potentially causing toxicity. Consider PPI discontinuation during methotrexate treatment, or dose adjustment of methotrexate.
* **CYP2C19 substrates (e.g., clopidogrel):** Pantoprazole can inhibit CYP2C19, potentially affecting the efficacy of clopidogrel. However, clinical significance is debated.
* **Warfarin:** PPIs may increase INR and prothrombin time in patients taking warfarin. Monitor INR closely.
* **Drugs dependent on gastric pH:** Absorption of drugs such as ketoconazole, itraconazole, and certain antiretrovirals may be decreased.
## Monitoring
* Monitor for signs and symptoms of C. difficile-associated diarrhea.
* Monitor serum magnesium levels periodically, especially with prolonged use (≥1 year).
* Monitor for signs and symptoms of fractures.
* Consider monitoring vitamin B12 levels with prolonged use.
## Clinical Pearls
* Administer 30 minutes before a meal.
* For IV administration, reconstitute and infuse over 15 minutes.
* IV to PO switch can be done when clinically indicated.
* Long-term PPI use should be reserved for specific indications with periodic reassessment.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information or a reliable drug reference for complete details and to ensure accuracy before making clinical decisions.*
