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Pantoprazole

Pantoprazole

Protonix Pantoloc Pantozol Protium Zurcal

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Updated: December 06, 2025

Overview

Pantoprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion by irreversibly blocking the H+/K+ ATPase enzyme system in gastric parietal cells. It is widely used for acid-related gastrointestinal disorders and offers prolonged acid suppression compared to H2-receptor antagonists. Pantoprazole demonstrates excellent efficacy in healing erosive esophagitis and managing gastroesophageal reflux disease (GERD). Its favorable safety profile and predictable pharmacokinetics make it suitable for both short-term and maintenance therapy. Unlike some other PPIs, pantoprazole has fewer drug interactions due to its lower affinity for CYP2C19 isoenzyme.

Drug Class

Substituted benzimidazole proton pump inhibitor Gastric acid secretion inhibitor Therapeutic category: Antiulcer agent

Mechanism of Action

Irreversibly binds to H+/K+ ATPase proton pumps in gastric parietal cells Converts to active sulfenamide form in acidic conditions Blocks final step of gastric acid secretion Produces dose-dependent inhibition of basal and stimulated acid secretion

Pharmacokinetics

Absorption: Oral bioavailability ~77% (delayed by food) Distribution: Volume of distribution 0.15 L/kg 97-99% protein bound Metabolism: Hepatic via CYP2C19 (major) and CYP3A4 (minor) No active metabolites Excretion: 71% renal (as metabolites) 18% fecal Half-life: 1 hour (prolonged to 3.5-10 hours in hepatic impairment)

Pharmacodynamics

Onset: 2.5 hours (oral) Peak effect: 4 hours Duration: >24 hours Maintains gastric pH >4 for 15-21 hours/day No effect on gastric emptying or esophageal motility

Indications

• Treatment of erosive esophagitis associated with GERD • Maintenance therapy for healed erosive esophagitis • Pathological hypersecretory conditions (Zollinger-Ellison syndrome) • Short-term treatment of duodenal ulcers • Adjuvant therapy for Helicobacter pylori eradication (in combination regimens)

Contraindications

Absolute: • Hypersensitivity to pantoprazole or substituted benzimidazoles • Concomitant use with rilpivirine-containing products Relative: • Severe hepatic impairment (Child-Pugh C) • Osteoporosis or risk factors for bone fractures • Vitamin B12 deficiency

Dosage & Administration

GERD/Erosive Esophagitis: 40 mg PO once daily for 8 weeks Maintenance: 40 mg PO daily Zollinger-Ellison Syndrome: Initial 40 mg PO bid, titrate to response (max 240 mg/day) IV Administration: 40 mg daily (15-minute infusion) for 7-10 days H. pylori Eradication: 40 mg PO bid as part of combination therapy

Special Populations

Pediatric: ≥5 years Weight-based dosing (20-40 mg daily) Geriatric: No dose adjustment needed Renal impairment: No dose adjustment required Hepatic impairment: Reduce dose to 20 mg daily in severe cirrhosis

Adverse Effects

Common (>10%): • Headache (12%) • Diarrhea (8.5%) • Flatulence (6.5%) Serious (<1%): • Clostridioides difficile-associated diarrhea • Acute interstitial nephritis • Hypomagnesemia (with prolonged use) • Vitamin B12 deficiency (long-term use)

Drug Interactions

• Atazanavir: Reduced absorption (avoid concomitant use) • Warfarin: Potential INR elevation (monitor coagulation) • Methotrexate: May increase methotrexate levels • Clopidogrel: Possible reduced antiplatelet effect (CYP2C19 interaction) • Iron salts: Reduced iron absorption (separate administration)

Warnings & Precautions

• Long-term use associated with increased risk of fractures • Vitamin B12 deficiency with prolonged therapy (>3 years) • Hypomagnesemia reported with prolonged use • May mask symptoms of gastric malignancy • Increased risk of C. difficile infection

Pregnancy & Lactation

Pregnancy: FDA Category B Animal studies show no risk, but human data limited Use only if clearly needed Lactation: Excreted in breast milk Consider risk/benefit AAP considers compatible with breastfeeding

Monitoring Parameters

• Magnesium levels (with prolonged therapy) • Renal function (serum creatinine) • Bone density (long-term use) • Vitamin B12 status (chronic therapy) • GI symptom resolution

Patient Counseling

• Take 30 minutes before breakfast (morning dose) • Swallow tablets whole; do not crush or chew • Report severe diarrhea, abdominal cramps, or bloody stools • Long-term use may require magnesium/Vitamin B12 supplements • Avoid concurrent use of antacids (separate by 2 hours)

Storage & Stability

Tablets: Store at 20-25°C (68-77°F) Protect from moisture IV powder: Store at controlled room temperature Reconstituted solution stable for 2 hours at room temperature

Clinical Pearls

• IV formulation useful for hospitalized patients unable to take oral medications • Consider periodic drug holidays for chronic users • More pH-stable than omeprazole (less affected by CYP2C19 polymorphisms) • Preferred PPI in warfarin users due to fewer interactions • Always rule out malignancy before starting long-term therapy

References

• UpToDate: Pantoprazole drug information • Protonix® (pantoprazole) prescribing information, Pfizer • Katz PO, et al. Am J Gastroenterol. 2013;108(3):308-28 (GERD guidelines) • Micromedex® Healthcare Series: Pantoprazole monograph