Medically reviewed on Nov 15, 2018
(pan TOE pra zole)
- Pantoprazole Magnesium
- Pantoprazole Sodium
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Protonix: 40 mg (1 ea, 30 ea) [contains polysorbate 80]
Solution Reconstituted, Intravenous:
Generic: 40 mg (1 ea)
Solution Reconstituted, Intravenous [preservative free]:
Protonix: 40 mg (1 ea) [contains edetate disodium]
Tablet Delayed Release, Oral:
Protonix: 20 mg, 40 mg
Generic: 20 mg, 40 mg
Brand Names: U.S.
- Proton Pump Inhibitor
- Substituted Benzimidazole
Proton pump inhibitor, suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump
Rapid, well absorbed
Children and Adolescents (Kearns 2008): IV (2 to 16 years of age): 0.22 ± 0.14 L/kg; Oral (5 to 16 years of age): 0.24 ± 0.09 L/kg
Adults: 11 to 23.6 L
Extensively hepatic; CYP2C19 (demethylation), CYP3A4; no evidence that metabolites have pharmacologic activity
Urine (71% as metabolites); feces (18%); pantoprazole clearance increased with weight and age (Pettersen 2009)
Onset of Action
Onset of action: Acid secretion: Oral: 2.5 hours; IV: 15 to 30 minutes
Maximum effect: IV: 2 hours
Time to Peak
Children and Adolescents (Kearns 2008): IV (2 to 16 years of age): 0.34 ± 0.12 hours; Oral (5 to 16 years of age): 2.54 ± 0.72 hours
Adults: Oral: 2.5 hours
Duration of Action
Oral, IV: 24 hours
Neonates (PMA: 37 to 44 weeks): ~3 hours (Ward 2010)
Children and Adolescents (Kearns 2008): IV (2 to 16 years of age): 1.22 ± 0.68 hours; Oral (5 to 16 years of age): 1.27 ± 1.29 hours
Adults: 1 hour; increased to 3.5 to 10 hours with CYP2C19 deficiency
98%, primarily to albumin
Special Populations: Hepatic Function Impairment
Increase in serum elimination half-life to 7 to 9 hours; AUC increases by 5- to 7-fold.
Special Populations: Elderly
Moderate increase in AUC (43%) and Cmax (26%) after oral administration.
Special Populations: Gender
A modest increase in AUC and Cmax in women.
Use: Labeled Indications
Erosive esophagitis associated with gastroesophageal reflux disease: Short-term treatment (up to 8 weeks) in the healing and symptomatic relief of erosive esophagitis in adults and pediatric patients 5 years and older.
Maintenance of healing of erosive esophagitis: Maintenance of healing of erosive esophagitis and reduction in relapse rates of daytime and nighttime heartburn symptoms in adult patients with gastroesophageal reflux disease (GERD).
Pathological hypersecretory conditions, including Zollinger-Ellison syndrome: Long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
Gastroesophageal reflux disease associated with a history of erosive esophagitis: Short-term treatment (7 to 10 days) of adult patients with gastroesophageal reflux disease (GERD) and a history of erosive esophagitis.
Pathological hypersecretory conditions, including Zollinger-Ellison: Treatment of adult patients with pathological hypersecretory conditions, including Zollinger-Ellison syndrome.
Off Label Uses
Data from a multicenter, double-blinded, placebo-controlled trial as well as from a double-blinded non-inferiority trial support the use of pantoprazole for the treatment of dyspepsia [Jung 2016], [van Rensburg 2008]. In addition, data from a systematic review support the use of pantoprazole for the treatment of patients with ulcer and reflux-like functional dyspepsia [Pinto-Sanchez 2017].
Based on the American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines for the management of dyspepsia, the use of pantoprazole is effective and recommended treatment for dyspepsia and functional dyspepsia in patients <60 years of age who are H. pylori negative or who remain symptomatic after H. pylori eradication therapy [ACG/CAG [Moayyedi 2017]].
Helicobacter pylori eradication
Based on the American College of Gastroenterology Clinical Guideline for Treatment of Helicobacter pylori infection, the use of proton pump inhibitors is effective and recommended in the treatment of H. pylori infection [Chey 2017].
Prevention of NSAID-induced ulcers
According to the American College of Gastroenterology 2009 Guidelines for Prevention of NSAID-Related Ulcer Complications, proton pump inhibitors (including pantoprazole) are effective and recommended in the prophylaxis of gastric and duodenal ulcers in patients receiving NSAID therapy [Lanza 2009].
Data from a randomized, double-blind, multicenter, parallel-group study and from a limited number of patients in a placebo-controlled, double-blind, parallel-group study, support the use of pantoprazole in the prevention of NSAID-induced ulcers [Bianchi Porro 2000], [Regula 2006].
Prevention of rebleeding in peptic ulcer bleed
Data from multiple randomized clinical trials including both open-label and double-blinded, randomized trials in patients with active peptic ulcer bleed treated with either continuous infusion or intermittent pantoprazole after endoscopic hemostasis support the use of either continuous infusion or intermittent pantoprazole for the treatment of this condition [Hsu 2010], [Hung 2007], [Yamada 2012], [Zargar 2006].
Based on the International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding, the use of an intravenous bolus followed by continuous infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy [Barkun 2010]. A meta-analysis concluded that the use of intermittent proton pump inhibitors (PPIs) was comparable to the use of continuous infusion PPIs in patients with high-risk endoscopic findings [Sachar 2014]. The use of intermittent infusions may be preferable considering the lower cost and resource utilization associated with the use of intermittent PPI therapy. However, intermittent dosing may still be preferred for the patient with low risk of recurrent bleeding (eg, clean ulcer base [Forrest type III]) [Lau 2013]. The American College of Gastroenterology Guidelines for Management of Patients with Ulcer Bleeding recommends oral PPI therapy for long term prophylaxis of recurrent bleeding ulcers; standard PPI therapy is recommended for ulcers with a flat pigmented spot or clean base [Laine 2012].
Stress ulcer prophylaxis in critically ill patients
Dosing for this indication has not been established; however, data from one study demonstrated that intermittent IV pantoprazole using multiple dosing regimens (ie, 40 mg every 24 hours, 40 mg every 12 hours, 80 mg every 24 hours, 80 mg every 12 hours, or 80 mg every 8 hours) effectively controls gastric pH (ie, maintains pH ≥4) compared to cimetidine (300 mg bolus followed by 50 mg/hour) [Somberg 2008]. Additional data is necessary to further define the role of pantoprazole in this setting.
Based on the Surviving Sepsis Campaign International Guidelines for the Management of Severe Sepsis and Septic Shock, stress ulcer prophylaxis using a PPI or a histamine H2-receptor antagonist is recommended in sepsis or septic shock patients who have GI bleeding risk factors.
Hypersensitivity (eg, anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute interstitial nephritis, urticaria) to pantoprazole, other substituted benzimidazole proton pump inhibitors, or any component of the formulation; in combination with rilpivirine-containing products.
Canadian labeling: Additional contraindications (not in US labeling): Concomitant use with rilpivirine
Dyspepsia (off-label use): Oral: 20 to 40 mg once daily for 4 weeks (Jung 2016, Pinto-Sanchez 2017, van Rensburg 2008)
Erosive esophagitis associated with GERD:
Treatment: 40 mg once daily for up to 8 weeks; an additional 8 weeks may be used in patients who have not healed after an 8-week course. Lower doses (20 mg once daily) have been used successfully in mild GERD treatment (Dettmer 1998).
Maintenance of healing: 40 mg once daily; 20 mg once daily has been used successfully in maintenance of healing (Escourrou 1999). Note: Has not been studied beyond 12 months.
IV: 40 mg once daily for 7 to 10 days
Pathological hypersecretory conditions, including Zollinger-Ellison syndrome:
Oral: Initial: 40 mg twice daily; adjust dose based on patient needs; doses up to 240 mg daily have been administered
IV: 80 mg every 12 hours; adjust dose based on acid output measurements; 160 to 240 mg daily in divided doses has been used for a limited period (up to 7 days)
Prevention of rebleeding in peptic ulcer bleed (off-label use):
Continuous infusion: Loading dose of 80 mg, followed by 8 mg/hour infusion for 72 hours (Barkun 2010; Zargar 2006).
Intermittent dosing: Loading dose of 80 mg followed by either 40 mg every 12 hours for 72 hours (Hung 2007; Yamada 2012) or 40 mg every 6 hours for 72 hours (Hsu 2009). May also administer 40 mg every 12 hours for 72 hours without a loading dose (Yuksel 2008).
Note: After completion, continue therapy with a single daily-dose oral PPI for a duration dictated by the underlying etiology (Barkun 2010; Laine 2012).
Oral: 40 mg once daily for 2 to 4 weeks (treatment of duodenal ulcer) or 4 to 8 weeks (treatment of gastric ulcer) (Pantoloc Canadian product labeling)
Helicobacter pylori eradication (off-label use): Oral: American College of Gastroenterology guidelines (Chey 2007; Chey 2017):
Clarithromycin triple regimen: 40 to 80 mg twice daily in combination with clarithromycin 500 mg twice daily and either amoxicillin 1 g twice daily or metronidazole 500 mg 3 times per day; continue regimen for 14 days. Note: Avoid use of clarithromycin triple therapy in patients with risk factors for macrolide resistance (eg, prior macrolide exposure, local clarithromycin resistance rates ≥15%, eradication rates with clarithromycin-based regimens ≤85%) (ACG [Chey 2017]; Fallone 2016).
Bismuth quadruple regimen: 40 mg twice daily in combination with tetracycline 500 mg 4 times per day, metronidazole 250 mg 4 times per day or 500 mg 3 or 4 times per day, and either bismuth subcitrate 120 to 300 mg 4 times per day or bismuth subsalicylate 300 mg 4 times per day; continue regimen for 10 to 14 days.
Concomitant regimen: 40 mg twice daily in combination with amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and either metronidazole or tinidazole 500 mg twice daily; continue regimen for 10 to 14 days.
Sequential regimen: 40 mg twice daily plus amoxicillin 1 g twice daily for 5 to 7 days; then continue pantoprazole along with clarithromycin 500 mg twice daily, and either metronidazole or tinidazole 500 mg twice daily for 5 to 7 days.
Hybrid regimen: 40 mg twice daily plus amoxicillin 1 g twice daily for 7 days; then continue pantoprazole and amoxicillin along with clarithromycin 500 mg twice daily, and either metronidazole or tinidazole 500 mg twice daily for 7 days.
Levofloxacin triple regimen: 40 mg twice daily in combination with amoxicillin 1 g twice daily and levofloxacin 500 mg once daily; continue regimen for 10 to 14 days.
Prevention of NSAID-induced ulcers (off-label): Oral: 20 to 40 mg once daily (Bianchi Prollo 2000; Lanza 2009; Regula 2006)
Discontinuation of therapy: Oral: Some experts recommend a step-down approach in order to avoid worsening or rebound symptoms. One strategy is to decrease the dose by 50% over 2 to 4 weeks. If the patient is already on the lowest possible dose, alternate day therapy may be considered. If symptoms worsen during treatment or after discontinuation, patient should be re-evaluated (Kim 2018).
Refer to adult dosing.
Erosive esophagitis associated with GERD:
Children 1 to 5 years: Limited data available: 0.3, 0.6, or 1.2 mg/kg/day once daily for 8 weeks was used in a dose-finding study of 60 patients with histologic or erosive esophagitis. High-dose treatment (1.2 mg/kg/day) was administered as a fixed dose of either: 15 mg for children 1 year of age or 20 mg for children 2 to 5 years of age. Patients with erosive esophagitis (n=4) received either 0.6 or 1.2 mg/kg/day (Baker 2010).
Children ≥5 years and Adolescents: Note: Consider a dose reduction in known CYP2C19 poor metabolizers.
≥15 to <40 kg: 20 mg once daily for up to 8 weeks
≥40 kg: 40 mg once daily for up to 8 weeks
Dosing: Renal Impairment
No dosage adjustment necessary; pantoprazole is not removed by hemodialysis.
Dosing: Hepatic Impairment
No dosage adjustment necessary; doses >40 mg daily have not been evaluated.
40 mg dose: Reconstitute 1 vial with 10 mL of NS; further dilute with 100 mL of D5W, NS, or LR to a final concentration of ~0.4 mg/mL.
80 mg dose: Reconstitute 2 vials each with 10 mL of NS; combine the content of both vials and further dilute with 80 mL of D5W, NS, or LR to a final concentration of ~0.8 mg/mL.
2-minute infusion: Reconstitute with 10 mL of NS to a final concentration of ~4 mg/mL.
A 2 mg/mL pantoprazole oral suspension may be made with pantoprazole tablets, sterile water, and sodium bicarbonate powder. Remove the Protonix® imprint from twenty 40 mg tablets with a paper towel dampened with ethanol (improves the look of product). Let tablets air dry. Crush the tablets in a mortar and reduce to a fine powder. Transfer to a 600 mL beaker, and add 340 mL sterile water. Place beaker on a magnetic stirrer. Add 16.8 g of sodium bicarbonate powder and stir for about 20 minutes until the tablet remnants have disintegrated. While stirring, add another 16.8 g of sodium bicarbonate powder and stir for about 5 minutes until powder has dissolved. Add enough sterile water for irrigation to bring the final volume to 400 mL. Mix well. Transfer to amber-colored bottle. Label "shake well" and "refrigerate". Stable for 62 days refrigerated.Dentinger PJ, Swenson CF, and Anaizi NH, “Stability of Pantoprazole in an Extemporaneously Compounded Oral Liquid,” Am J Health Syst Pharm, 2002, 59(10):953-6.12040734
IV: Flush IV line before and after administration with D5W, NS, or LR. In-line filter not required.
2-minute infusion: The volume of reconstituted solution (4 mg/mL) may be administered intravenously over at least 2 minutes.
15-minute infusion: Infuse over ~15 minutes at a rate of ~7 mL/minute (3 mg/minute).
Continuous infusion: May also be administered as a continuous infusion for the prevention of rebleeding with in peptic ulcer bleed (off-label use).
Tablet: Should be swallowed whole, do not split, crush, or chew. May administer with or without food; concomitant administration of antacids does not affect absorption.
Delayed-release oral suspension: Should only be administered in apple juice or applesauce and taken ~30 minutes before a meal; do not chew or crush granules. Do not administer with any other liquid (eg, water) or foods.
Oral administration in applesauce: Sprinkle intact granules on 1 teaspoon of applesauce and swallow within 10 minutes of preparation.
Oral administration in apple juice: Empty intact granules into 5 mL of apple juice, stir for 5 seconds (granules will not dissolve), and swallow immediately after preparation. Rinse container once or twice with apple juice and swallow immediately.
Nasogastric tube administration: Separate the plunger from the barrel of a 60 mL catheter tip syringe and connect to a ≥16 French nasogastric tube. Holding the syringe attached to the tubing as high as possible, empty the contents of the packet into barrel of the syringe, add 10 mL of apple juice and gently tap/shake the barrel of the syringe to help empty the syringe. Add an additional 10 mL of apple juice and gently tap/shake the barrel to help rinse. Repeat rinse at least twice with 10 mL aliquots of apple juice. No granules should remain in the syringe.
IV: Due to EDTA in preparation, zinc supplementation may be needed in patients prone to zinc deficiency.
Oral: Store tablet and oral suspension at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).
IV: Prior to reconstitution, store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not freeze. Protect from light prior to reconstitution; upon reconstitution, protection from light is not required. Do not freeze reconstituted solution. Per manufacturer's labeling, reconstituted solution is stable at room temperature for up to 6 hours; further diluted (admixed) solution in D5W, LR, or NS should be stored at room temperature and used within 24 hours from the time of initial reconstitution. However, studies have shown that reconstituted solution (4 mg/mL) in polypropylene syringes is stable up to 96 hours at room temperature (Johnson 2005). Upon further dilution, the admixed solution should be used within 96 hours from the time of initial reconstitution. The preparation should be stored at 3°C to 5°C (37°F to 41°F) if it is stored beyond 48 hours to minimize discoloration.
Acalabrutinib: Proton Pump Inhibitors may decrease the serum concentration of Acalabrutinib. Avoid combination
Amphetamine: Proton Pump Inhibitors may increase the absorption of Amphetamine. Monitor therapy
Atazanavir: Proton Pump Inhibitors may decrease the serum concentration of Atazanavir. Management: See full drug interaction monograph for details. Consider therapy modification
Bisphosphonate Derivatives: Proton Pump Inhibitors may diminish the therapeutic effect of Bisphosphonate Derivatives. Monitor therapy
Bosutinib: Proton Pump Inhibitors may decrease the serum concentration of Bosutinib. Management: Consider alternatives to proton pump inhibitors, such as antacids or H2 receptor antagonists. Administer alternative agents more than 2 hours before or after bosutinib. Consider therapy modification
Capecitabine: Proton Pump Inhibitors may diminish the therapeutic effect of Capecitabine. Monitor therapy
Cefditoren: Proton Pump Inhibitors may decrease the serum concentration of Cefditoren. Management: If possible, avoid use of cefditoren with proton pump inhibitors (PPIs). Consider alternative methods to minimize/control acid reflux (eg, diet modification) or alternative antimicrobial therapy if use of PPIs can not be avoided. Consider therapy modification
Cefpodoxime: Proton Pump Inhibitors may decrease the serum concentration of Cefpodoxime. Monitor therapy
Cefuroxime: Proton Pump Inhibitors may decrease the absorption of Cefuroxime. Avoid combination
Clopidogrel: Pantoprazole may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Due to the possible risk for impaired clopidogrel effectiveness, clinicians should carefully consider the need for proton pump inhibitor therapy in patients receiving clopidogrel. Other acid-lowering therapies do not appear to share this interaction. Consider therapy modification
CYP2C19 Inducers (Strong): May increase the metabolism of CYP2C19 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification
Cysteamine (Systemic): Proton Pump Inhibitors may diminish the therapeutic effect of Cysteamine (Systemic). Monitor therapy
Dabrafenib: May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP2C19 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification
Dacomitinib: Proton Pump Inhibitors may decrease the serum concentration of Dacomitinib. Management: Avoid concurrent use of dacomitinib with proton pump inhibitors. Antacids may be used. Histamine H2-receptor antagonists (HR2A) may be used if dacomitinib is given at least 6 hours before or 10 hours after the H2RA. Avoid combination
Dasatinib: Proton Pump Inhibitors may decrease the serum concentration of Dasatinib. Management: Antacids (taken 2 hours before or after dasatinib administration) can be used in place of the proton pump inhibitor if some acid-reducing therapy is needed. Avoid combination
Delavirdine: Proton Pump Inhibitors may decrease the serum concentration of Delavirdine. Management: Chronic therapy with proton pump inhibitors (PPIs) should be avoided in patients treated with delavirdine. The clinical significance of short-term PPI therapy with delavirdine is uncertain, but such therapy should be undertaken with caution. Avoid combination
Dexmethylphenidate: Proton Pump Inhibitors may increase the absorption of Dexmethylphenidate. Specifically, proton pump inhibitors may interfere with the normal release of drug from the extended-release capsules (Focalin XR brand), which could result in both increased absorption (early) and decreased delayed absorption. Monitor therapy
Dextroamphetamine: Proton Pump Inhibitors may increase the absorption of Dextroamphetamine. Specifically, the dextroamphetamine absorption rate from mixed amphetamine salt extended release (XR) capsules may be increased in the first hours after dosing. Monitor therapy
Doxycycline: Proton Pump Inhibitors may decrease the bioavailability of Doxycycline. Monitor therapy
Enzalutamide: May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Conversely, concentrations of active metabolites may be increased for those drugs activated by CYP2C19. Management: Concurrent use of enzalutamide with CYP2C19 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP2C19 substrate should be performed with caution and close monitoring. Consider therapy modification
Erlotinib: Proton Pump Inhibitors may decrease the serum concentration of Erlotinib. Avoid combination
Fluconazole: May increase the serum concentration of Proton Pump Inhibitors. Monitor therapy
Gefitinib: Proton Pump Inhibitors may decrease the serum concentration of Gefitinib. Management: Avoid use of proton pump inhibitors (PPIs) with gefitinib when possible. If required, administer gefitinib 12 hours after administration of the PPI or 12 hours before the next dose of the PPI. Consider therapy modification
Indinavir: Proton Pump Inhibitors may decrease the serum concentration of Indinavir. Monitor therapy
Iron Salts: Proton Pump Inhibitors may decrease the absorption of Iron Salts. Exceptions: Ferric Carboxymaltose; Ferric Citrate; Ferric Gluconate; Ferric Hydroxide Polymaltose Complex; Ferric Pyrophosphate Citrate; Ferumoxytol; Iron Dextran Complex; Iron Isomaltoside; Iron Sucrose. Monitor therapy
Itraconazole: Proton Pump Inhibitors may decrease the serum concentration of Itraconazole. Consider therapy modification
Ketoconazole (Systemic): Proton Pump Inhibitors may decrease the serum concentration of Ketoconazole (Systemic). Ketoconazole (Systemic) may increase the serum concentration of Proton Pump Inhibitors. Consider therapy modification
Ledipasvir: Proton Pump Inhibitors may decrease the serum concentration of Ledipasvir. Management: PPI doses equivalent to omeprazole 20 mg or lower may be given with ledipasvir under fasted conditions. Administration with higher doses of PPIs, 2 hours after a PPI, or in combination with food and PPIs may reduce ledipasvir bioavailability. Consider therapy modification
Lumacaftor: May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Monitor therapy
Mesalamine: Proton Pump Inhibitors may diminish the therapeutic effect of Mesalamine. Proton pump inhibitor-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Consider avoiding concurrent administration of high-dose proton pump inhibitors (PPIs) with sustained-release mesalamine products. Consider therapy modification
Methotrexate: Proton Pump Inhibitors may increase the serum concentration of Methotrexate. Monitor therapy
Methylphenidate: Proton Pump Inhibitors may increase the absorption of Methylphenidate. Specifically, proton pump inhibitors may interfere with the normal release of drug from the extended-release capsules (Ritalin LA brand), which could result in both increased absorption (early) and decreased delayed absorption. Monitor therapy
Multivitamins/Minerals (with ADEK, Folate, Iron): Proton Pump Inhibitors may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, the absorption of iron may be decreased. Monitor therapy
Mycophenolate: Proton Pump Inhibitors may decrease the serum concentration of Mycophenolate. Specifically, concentrations of the active mycophenolic acid may be reduced. Monitor therapy
Nelfinavir: Proton Pump Inhibitors may decrease serum concentrations of the active metabolite(s) of Nelfinavir. Proton Pump Inhibitors may decrease the serum concentration of Nelfinavir. Avoid combination
Neratinib: Proton Pump Inhibitors may decrease the serum concentration of Neratinib. Specifically, proton pump inhibitors may reduce neratinib absorption. Avoid combination
Nilotinib: Proton Pump Inhibitors may decrease the serum concentration of Nilotinib. Management: Avoid this combination when possible since separation of doses is not likely to be an adequate method of minimizing the interaction. Consider therapy modification
PAZOPanib: Proton Pump Inhibitors may decrease the serum concentration of PAZOPanib. Avoid combination
Posaconazole: Proton Pump Inhibitors may decrease the serum concentration of Posaconazole. Consider therapy modification
Raltegravir: Proton Pump Inhibitors may increase the serum concentration of Raltegravir. Monitor therapy
Rilpivirine: Proton Pump Inhibitors may decrease the serum concentration of Rilpivirine. Avoid combination
Riociguat: Proton Pump Inhibitors may decrease the serum concentration of Riociguat. Monitor therapy
Risedronate: Proton Pump Inhibitors may diminish the therapeutic effect of Risedronate. Proton Pump Inhibitors may increase the serum concentration of Risedronate. This applies specifically to use of delayed-release risedronate. Avoid combination
Saquinavir: Proton Pump Inhibitors may increase the serum concentration of Saquinavir. Monitor therapy
Secretin: Proton Pump Inhibitors may diminish the diagnostic effect of Secretin. Specifically, use of PPIs may cause a hyperresponse in gastrin secretion in response to secretin stimulation testing, falsely suggesting gastrinoma. Management: Avoid concomitant use of proton pump inhibitors (PPIs) and secretin, and discontinue PPIs several weeks prior to secretin administration, with the duration of separation determined by the specific PPI. See full monograph for details. Consider therapy modification
Tipranavir: May decrease the serum concentration of Proton Pump Inhibitors. These data are derived from studies with Ritonavir-boosted Tipranavir. Monitor therapy
Velpatasvir: Proton Pump Inhibitors may decrease the serum concentration of Velpatasvir. Avoid combination
Voriconazole: May increase the serum concentration of Proton Pump Inhibitors. Proton Pump Inhibitors may increase the serum concentration of Voriconazole. Management: In patients receiving omeprazole 40 mg/day or greater, reduce omeprazole dose by half when initiating voriconazole. Monitor therapy
Chromogranin A (CgA) levels: Proton pump inhibitors (PPIs), including pantoprazole, may increase CgA levels, which may interfere with neuroendocrine tumor detection. To avoid interference, stop PPI therapy 14 days prior to CgA measurements.
Tetrahydrocannabinol (THC) urine screening tests: PPIs, including pantoprazole, may cause false-positive urine THC tests. Alternative confirmatory methods should be considered to verify positive results.
Incidences are associated with adults unless otherwise specified.
>10%: Central nervous system: Headache (adults 12%; children & adolescents: >4%)
1% to 10%:
Cardiovascular: Facial edema (children, adolescents, & adults: ≤4%), edema (≤2%), thrombophlebitis (IV: ≤2%)
Central nervous system: Dizziness (children, adolescents, & adults: ≤4%), vertigo (children, adolescents, & adults: ≤4%), depression (≤2%)
Dermatologic: Skin rash (adults: ≤2%; children & adolescents: >4%), urticaria (children, adolescents, & adults: ≤4%), pruritus (≤2%), skin photosensitivity (≤2%)
Endocrine & metabolic: Increased serum triglycerides (children, adolescents, & adults: ≤4%)
Gastrointestinal: Diarrhea (children, adolescents, & adults: 4% to 9%), abdominal pain (children & adolescents: >4%), vomiting (children, adolescents, & adults: ≥4%), constipation (children, adolescents, & adults: ≤4%), flatulence (children & adolescents: ≤4%), nausea (children & adolescents: ≤4%), xerostomia (≤2%)
Hematologic & oncologic: Leukopenia (≤2%), thrombocytopenia (≤2%)
Hepatic: Increased liver enzymes (children, adolescents, & adults: ≤4%), hepatitis (≤2%)
Hypersensitivity: Hypersensitivity reaction (children, adolescents, & adults: ≤4%)
Neuromuscular & skeletal: Arthralgia (children, adolescents, & adults: ≤4%), increased creatine phosphokinase (children, adolescents, & adults: ≤4%), myalgia (children, adolescents, & adults: ≤4%)
Ophthalmic: Blurred vision (≤2%)
Respiratory: Upper respiratory tract infection (children & adolescents: >4%)
Miscellaneous: Fever (adults: ≤2%; children & adolescents: >4%)
<1%, postmarketing, and/or case reports: Acute interstitial nephritis, ageusia, agranulocytosis, anaphylactic shock, anaphylaxis, angioedema, asthenia, bone fracture, Clostridioides (formerly Clostridium) difficile-associated diarrhea, confusion, cutaneous lupus erythematous, drowsiness, dysgeusia, erythema multiforme, fatigue, gastric polyp (fundic gland), hallucination, hepatic failure, hepatotoxicity, hypomagnesemia, hyponatremia, insomnia, jaundice, laboratory test abnormality (false-positive for THC), malaise, pancytopenia, pneumonia (Eom 2011), renal disease (chronic; Lazarus 2016), rhabdomyolysis, severe dermatological reaction, Stevens-Johnson syndrome, systemic lupus erythematosus, toxic epidermal necrolysis, weight changes
Concerns related to adverse effects:
• Carcinoma: Benign and malignant neoplasia has been observed in long-term (2-year) rodent studies; while not reported in humans, the relevance of these findings in regards to tumorigenicity in humans is not known.
• Clostridioides (formerly Clostridium) difficile-associated diarrhea (CDAD): Use of proton pump inhibitors (PPIs) may increase risk of CDAD, especially in hospitalized patients; consider CDAD diagnosis in patients with persistent diarrhea that does not improve. Use the lowest dose and shortest duration of PPI therapy appropriate for the condition being treated.
• Cutaneous and systemic lupus erythematosus: Has been reported as new onset or exacerbation of existing autoimmune disease; most cases were cutaneous lupus erythematosus (CLE), most commonly, subacute CLE (occurring within weeks to years after continuous therapy). Systemic lupus erythematosus (SLE) is less common (typically occurs within days to years after initiating treatment) and occurred primarily in young adults up to elderly patients. Discontinue therapy if signs or symptoms of CLE or SLE occur and refer to specialist for evaluation; most patients improve 4 to 12 weeks after discontinuation of pantoprazole.
• Fractures: Increased incidence of osteoporosis-related bone fractures of the hip, spine, or wrist may occur with PPI therapy. Patients on high-dose or long-term therapy (≥1 year) should be monitored. Use the lowest effective dose for the shortest duration of time, use vitamin D and calcium supplementation, and follow appropriate guidelines to reduce risk of fractures in patients at risk.
• Fundic gland polyps: Use of PPIs increases risk of fundic gland polyps, especially with long-term use >1 year. May occur without symptoms, but nausea, vomiting, or abdominal pain may occur; GI bleeding and/or anemia may occur with ulcerated polyps. Diagnosis of polyps may also increase risk for small intestinal blockage. Use the lowest dose and shortest duration of PPI therapy appropriate for the condition being treated.
• GI infection (eg, Salmonella, Campylobacter): Use of PPIs may increase risk of these infections.
• Hepatic effects: Mild, transient transaminase elevations have been observed.
• Hypomagnesemia: Reported rarely, usually with prolonged PPI use of ≥3 months (most cases >1 year of therapy). May be symptomatic or asymptomatic; severe cases may cause tetany, seizures, and cardiac arrhythmias. Consider obtaining serum magnesium concentrations prior to beginning long-term therapy, especially if taking concomitant digoxin, diuretics, or other drugs known to cause hypomagnesemia; and periodically thereafter. Hypomagnesemia may be corrected by magnesium supplementation, although discontinuation of pantoprazole may be necessary; magnesium levels typically return to normal within 2 weeks of stopping.
• Infusion-related reactions: Thrombophlebitis and serious hypersensitivity reactions, including anaphylaxis, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported with IV administration.
• Interstitial nephritis: Acute interstitial nephritis has been observed in patients taking PPIs; may occur at any time during therapy and is generally due to an idiopathic hypersensitivity reaction. Discontinue if acute interstitial nephritis develops.
• Vitamin B12 deficiency: Prolonged treatment (≥2 years) may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency. The magnitude of the deficiency is dose-related and the association is stronger in females and those younger in age (<30 years of age); prevalence is decreased after discontinuation of therapy (Lam 2013).
• Gastric malignancy: Relief of symptoms does not preclude the presence of a gastric malignancy.
Concurrent drug therapy issues:
• Clopidogrel: PPIs may diminish the therapeutic effect of clopidogrel, thought to be due to reduced formation of the active metabolite of clopidogrel. The manufacturer of clopidogrel recommends either avoidance of both omeprazole (even when scheduled 12 hours apart) and esomeprazole or use of a PPI with comparatively less effect on the active metabolite of clopidogrel. Of the PPIs, pantoprazole has the lowest degree of CYP2C19 inhibition in vitro (Li 2004) and has been shown to have less effect on conversion of clopidogrel to its active metabolite compared to omeprazole (Angiolillo 2011). In contrast to these warnings, others have recommended the continued use of PPIs, regardless of the degree of inhibition, in patients with a history of GI bleeding or multiple risk factors for GI bleeding who are also receiving clopidogrel since no evidence has established clinically meaningful differences in outcome; however, a clinically significant interaction cannot be excluded in those who are poor metabolizers of clopidogrel (Abraham 2010; Levine 2011).
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Dosage form specific issues:
• Edetate sodium (EDTA): Some dosage forms may contain edetate sodium; use caution in patients who are at risk for zinc deficiency if other EDTA-containing solutions are coadministered.
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer's labeling.
• Appropriate use: Helicobacter pylori eradication: Short-term combination therapy (≤7 days) has been associated with a higher incidence of treatment failure. The American College of Gastroenterology recommends 10 to 14 days of therapy (triple or quadruple) for eradication of H. pylori (Chey 2017).
• Laboratory test interference: Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acid; may cause false-positive results in diagnostic investigations for neuroendocrine tumors. Temporarily stop pantoprazole treatment at least 14 days before CgA test; if CgA level is high, repeat test to confirm. Use same commercial laboratory for testing to prevent variable results.
Bone loss and fractures, CDAD, magnesium (baseline and periodically thereafter), and serum gastrin levels
Hypersecretory disorders: Acid output measurements, target level <10 mEq/hour (<5 mEq/hour if prior gastric acid-reducing surgery)
Adverse events have not been observed in animal reproduction studies.
Recommendations for the treatment of GERD in pregnancy are available. As in nonpregnant patients, lifestyle modifications followed by other medications are the initial treatments (Body 2016; Huerta-Iga 2016; Katz 2013; van der Woude 2014). Based on available data, PPIs may be used when clinically indicated (Body 2016; Matok 2012; Pasternak 2010; van der Woude 2014).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience headache, diarrhea, nausea, vomiting, flatulence, common cold symptoms, or joint pain. Have patient report immediately to prescriber signs of low magnesium (mood changes; muscle pain or weakness; muscle cramps or spasms; seizures; tremors; lack of appetite; severe nausea or vomiting; or an abnormal heartbeat), signs of lupus (rash on the cheeks or other body parts, sunburn easy, muscle or joint pain, angina or shortness of breath, or swelling in the arms or legs), signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), severe dizziness, passing out, severe abdominal pain, bone pain, chills, pharyngitis, excessive weight loss, injection site irritation, signs of Clostridium difficile (C. diff)-associated diarrhea (abdominal pain or cramps, severe diarrhea or watery stools, or bloody stools), or signs of Stevens-Johnson syndrome/toxic epidermal necrolysis (red, swollen, blistered, or peeling skin [with or without fever]; red or irritated eyes; or sores in mouth, throat, nose, or eyes) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: proton pump inhibitors
Other brands: Protonix