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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 and maintenance, symptomatic GERD * Peptic ulcer disease (PUD) - duodenal ulcers, gastric ulcers, NSAID-associated ulcers * Zollinger-Ellison syndrome * H. pylori eradication (in combination with antibiotics) ## Adult Dosing * **GERD (erosive esophagitis healing):** 40 mg orally or intravenously once daily for 4-8 weeks. * **GERD (maintenance):** 20-40 mg orally once daily. * **Symptomatic GERD:** 20 mg orally once daily. * **PUD (duodenal/gastric ulcer):** 40 mg orally or intravenously once daily for 4-10 weeks. * **NSAID-associated ulcer:** 40 mg orally once daily for up to 8 weeks. * **H. pylori eradication:** 40 mg orally twice daily for 7-14 days, in combination with amoxicillin and clarithromycin, or other appropriate antibiotics. * **Zollinger-Ellison syndrome:** Starting dose is typically 40 mg orally or intravenously twice daily. Doses can be titrated up to 240 mg daily. ## Pediatric Dosing Dosing varies significantly by indication and age. Local protocol should be consulted. * **GERD (age 5-16 years):** * Erosive esophagitis healing: 20-40 mg orally once daily for 4-8 weeks. * Symptomatic GERD: 20 mg orally once daily. ## Dose Adjustments No dose adjustment is typically required for renal impairment. For severe hepatic impairment, consider reducing the daily dose to 20 mg. ## Contraindications * Known hypersensitivity to pantoprazole or any component of the formulation. ## Adverse Effects Common: Headache, diarrhea, nausea, abdominal pain, flatulence, dizziness. Long-term use may be associated with an increased risk of: * Fractures (hip, wrist, spine) - especially with high doses or prolonged duration (>1 year). * Clostridium difficile-associated diarrhea. * Vitamin B12 deficiency. * Hypomagnesemia. * Rebound acid hypersecretion upon discontinuation. ## Key Drug Interactions * **Drugs dependent on gastric pH for absorption:** May decrease absorption of drugs like ketoconazole, itraconazole, posaconazole, and certain HIV protease inhibitors (e.g., atazanavir). May increase absorption of drugs like digoxin. * **Methotrexate:** PPIs may increase methotrexate levels, potentially leading to toxicity. * **CYP2C19 substrates:** Pantoprazole can inhibit CYP2C19, potentially increasing levels of drugs like clopidogrel (though clinical significance is debated) and citalopram. ## Monitoring * Monitor for signs and symptoms of C. difficile infection. * Consider periodic serum magnesium levels, especially with prolonged use or concomitant diuretic/digoxin use. * Assess for symptoms of GERD or PUD to guide continued therapy. ## Clinical Pearls * Administer oral pantoprazole 30 minutes before a meal. * For IV administration, reconstitute and infuse as directed; do not administer with other medications in the same line. * Tapering may be considered to minimize rebound acid hypersecretion upon discontinuation. *** *Please verify current prescribing information and institutional protocols for definitive guidance.*