Bedside Snapshot

Use It For: Peptic ulcer bleeding after endoscopic hemostasis; suspected upper GI bleeding awaiting endoscopy; stress ulcer prophylaxis in high-risk ICU patients; erosive esophagitis when NPO
Adult Dose: Ulcer bleed after hemostasis: 80 mg IV, then 8 mg/hr for 72 hr (or 80 mg IV, then 40 mg IV 2–4 times daily)
Stress ulcer prophylaxis: 40 mg IV/PO once daily
Zollinger-Ellison: 80 mg IV every 12 hr (max 240 mg/day)
Pediatric Dose: GERD with erosive esophagitis, 3 months and older: 0.8 mg/kg IV (infants <12.5 kg) or 10–40 mg IV once daily by weight (max 40 mg/day). GI bleeding: specialist use only
Onset / Duration: IV: 15–30 min / 24 hr; PO: partial effect by 2.5 hr, near-maximal after about 7 days of daily dosing / 24 hr
Do Not Give / Hold If: Hypersensitivity to any PPI (substituted benzimidazole); taking rilpivirine (Edurant, Odefsey); hold for blistering rash or unexplained creatinine rise
Watch For: Ongoing bleeding (melena, falling Hgb, tachycardia); IV-site thrombophlebitis; C. difficile (new watery diarrhea); interstitial nephritis (rising creatinine)
Reversal / Rescue: No specific reversal: supportive care; not removed by hemodialysis. Stop for anaphylaxis, severe skin reaction or suspected interstitial nephritis
Must Remember: A PPI does not stop active bleeding: resuscitate and arrange early endoscopy. Give through a dedicated line or a Y-site with D5W or NS only; never with midazolam

Indications

ED / ICU / Transport

Peptic ulcer bleeding after endoscopic hemostasis: ulcers with active bleeding, a nonbleeding visible vessel or an adherent clot get high-dose therapy for 3 days, then twice daily to day 14 (off-label)
Suspected upper GI bleeding awaiting endoscopy: it may be considered to downstage ulcer stigmata. Never a reason to delay endoscopy (off-label)
Stress ulcer prophylaxis: critically ill adults with coagulopathy, shock or chronic liver disease get it, and so do neurocritical care adults (SCCM/ASHP 2024: a low-dose PPI or H2RA). Adults with sepsis or septic shock and GI-bleeding risk factors: Surviving Sepsis Campaign 2026 prefers a PPI. Invasively ventilated adults see less clinically important bleeding (off-label). Wang 2024 meta-analysis: PPIs cut clinically important upper GI bleeding (RR 0.51, high certainty) with little or no effect on overall mortality (RR 0.99, low certainty). An intermediate-credibility subgroup analysis suggests lower 90-day mortality in less severely ill patients and possibly higher mortality in more severely ill patients
GERD with a history of erosive esophagitis: IV for up to 10 days in adults (7 days in children 3 months and older) when they cannot take it by mouth
Zollinger-Ellison syndrome and other hypersecretory states: IV or PO, titrated to acid output

Other Uses

Erosive esophagitis from GERD: oral healing course in adults and children 5 years and older, then maintenance in adults
Peptic ulcer disease and NSAID or antiplatelet gastroprotection: patients on clopidogrel are covered too, and there pantoprazole is a preferred PPI (off-label)

Not for Variceal Bleeding: Suspected variceal hemorrhage calls for a vasoactive drug such as octreotide, antibiotic prophylaxis (e.g. ceftriaxone) and band ligation. A PPI is no substitute for any of the three.

Dosing & Administration

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

IV (Protonix I.V. and generics): 40 mg lyophilized powder in a single-dose vial. Each vial contains edetate disodium 1 mg.
Delayed-release tablets: 20 mg and 40 mg
Delayed-release oral suspension: 40 mg granule packet for applesauce, apple juice or a feeding tube. It is a fixed dose and cannot be divided

Adult Dosing

Indication	Dose & Route	Repeat / Max	Notes
Peptic ulcer bleeding after endoscopic hemostasis (high-risk stigmata)	80 mg IV bolus, then 8 mg/hr continuous IV infusion for 72 hr	Max 8 mg/hr; 72 hr, then 40 mg PO twice daily to day 14, then once daily	Intermittent option: 80 mg IV, then 40 mg IV 2–4 times daily for 3 days; cost and ease guide the choice. Off-label
Suspected upper GI bleeding, before endoscopy	80 mg IV bolus; continue per GI or local protocol until endoscopy	No fixed max: high-dose regimen per local GI protocol; never delay endoscopy	ESGE 2026 suggests considering it; ACG 2021 makes no recommendation for or against. Off-label
Stress ulcer prophylaxis (ICU)	40 mg IV/PO once daily	Max 40 mg/day (low-dose regimen)	With risk factors: coagulopathy, shock or chronic liver disease; SCCM/ASHP 2024 also suggests it for neurocritical care adults. Ventilation alone is not an established risk factor (but see REVISE). SCCM/ASHP 2024 rates a low-dose PPI or H2RA as equal first-line options; SSC 2026 suggests a PPI in sepsis, with an H2RA as a reasonable alternative when a PPI is not available. Enterally fed, low-risk patients do not need it. Stop when risk resolves and before ICU transfer out. Off-label
GERD with history of erosive esophagitis, unable to take PO	40 mg IV once daily, push over at least 2 min or infuse over 15 min	Max 40 mg/day; up to 10 days	Switch to oral therapy as soon as tolerated
Erosive esophagitis (oral)	40 mg PO once daily for up to 8 weeks	Max 40 mg/day; may repeat one 8-week course	Maintenance after healing: 40 mg PO once daily
Zollinger-Ellison syndrome	80 mg IV every 12 hr; or 40 mg PO twice daily	IV up to 80 mg every 8 hr (240 mg/day); PO up to 240 mg/day	Specialist-directed; titrate to measured acid output

Pediatric Dosing

Indication	Dose (per kg) & Route	Max Single / Max Total	Notes
GERD with erosive esophagitis history, IV, 3 months to <1 yr	<12.5 kg: 0.8 mg/kg IV once daily; ≥12.5 kg: 10 mg IV once daily	Max 10 mg/day; up to 7 days	Infuse over 15 min (about 1.3 mg/mL); switch to oral therapy when able
GERD with erosive esophagitis history, IV, 1–17 yr	≤15 kg: 10 mg; >15–40 kg: 20 mg; >40 kg: 40 mg IV once daily	Max 40 mg/day; up to 7 days	Infuse over 15 min (about 0.4 mg/mL); IV push is not labeled in children
Erosive esophagitis, PO, 5 yr and older	15 to <40 kg: 20 mg PO once daily; ≥40 kg: 40 mg PO once daily	Max 40 mg/day; up to 8 weeks	Give 20 mg as a whole 20 mg tablet: the 40 mg granule packet cannot be divided. Swallow tablets whole; no age-appropriate oral form under 5 yr
Neonates and infants <3 months	Not established in children of this age	—	Effectiveness for erosive esophagitis not demonstrated in infants <1 yr (label)
Upper GI bleeding or stress ulcer prophylaxis	Not established in children	Never exceed the adult dose	Pediatric GI or critical care direction only (specialist use)

For safe pediatric calculations, use weight-based dosing.

Continuous Infusion

Setting	Example Concentration	Start	Titrate	Usual Range / Max
Peptic ulcer bleeding after hemostasis	80 mg in 100 mL D5W or NS (0.8 mg/mL), example (institution-specific)	8 mg/hr (10 mL/hr at 0.8 mg/mL) after the 80 mg bolus	Not titrated	8 mg/hr for 72 hr

Preparation & Administration

Reconstitution: 40 mg vial with 10 mL 0.9% sodium chloride (about 4 mg/mL)
Push rate: adults only, over at least 2 min
Intermittent infusion: dilute in 100 mL D5W or NS (about 0.4 mg/mL) and infuse over about 15 min; infants 3 months to <1 yr: dilute with 21 mL NS (about 1.3 mg/mL)
Line and flush: dedicated line, or a Y-site carrying only D5W or NS; flush before and after each dose with D5W or NS
Stability: vials at 20–25°C (68–77°F), protected from light. Reconstituted vial (4 mg/mL), at room temperature up to 30°C: up to 6 hr before further dilution, or up to 24 hr for adult IV push. Diluted bag: use within 24 hr of the initial reconstitution. Do not freeze
Oral: Swallow tablets whole, with or without food. Never split, crush or chew them. Granules go 30 min before a meal in applesauce or apple juice
Feeding tube: A whole 40 mg granule packet in apple juice only, through a 16 French or larger NG or gastrostomy tube. Never split a packet for a smaller dose

Contraindications & Precautions

Contraindications

Known hypersensitivity to pantoprazole, any formulation component or any substituted benzimidazole PPI (anaphylaxis, angioedema, bronchospasm, interstitial nephritis, urticaria)
Concurrent rilpivirine-containing products (e.g. Edurant, Odefsey): loss of rilpivirine effect and HIV resistance

Precautions

Upper GI bleeding: The IV product's safety and effectiveness for bleeding are not established in labeling. Guideline use is off-label and adjunctive to resuscitation and endoscopy
Alarm features: Symptom relief does not rule out gastric cancer. Weight loss, dysphagia or anemia need endoscopy
Zinc deficiency risk: The IV product contains edetate disodium (EDTA), a zinc chelator. Consider zinc supplementation in patients prone to zinc deficiency. Use caution with other EDTA-containing IV products
Long-term use: Hypomagnesemia, B12 deficiency, fractures and fundic gland polyps all climb with duration. Use the lowest dose for the shortest appropriate course

Hold / Reassess If

Rash with blistering, mucosal lesions, fever or eosinophilia: stop and evaluate for a severe cutaneous reaction
Rising creatinine with no other cause: stop and evaluate for acute interstitial nephritis
Painful, red, cord-like IV site: remove the catheter if indicated
Stress ulcer risk factors resolved (shock reversed, coagulopathy corrected): stop prophylaxis

Adverse Effects & Toxicity

Common

Headache (12%)
Diarrhea (9%) and nausea (7%)
Abdominal pain (6%), vomiting (4%), flatulence (4%)
Dizziness (3%) and arthralgia (3%)
IV: injection-site thrombophlebitis

Serious / Life-Threatening

Effect	Recognition	Management
Anaphylaxis and severe cutaneous reactions	Hypotension, angioedema, bronchospasm; or blistering rash, mucosal erosions, fever (SJS/TEN, DRESS, AGEP)	Stop; treat anaphylaxis; avoid all PPIs if severe
Acute interstitial nephritis	Rising creatinine at any point in therapy, sometimes with fever, rash or eosinophilia	Stop; nephrology evaluation
Clostridioides difficile infection	New watery diarrhea, abdominal pain, fever, leukocytosis	Test stool; treat; reassess the PPI indication
Hypomagnesemia	Usually after 3+ months (most after 1 year): tetany, seizures, arrhythmias, QT prolongation; may bring low K⁺ and Ca²⁺	Replace Mg²⁺; may need the PPI stopped to correct it
Hepatic effects	Mild, transient transaminase rise; rare postmarketing hepatocellular injury with jaundice or hepatic failure	Check liver tests if jaundice or symptoms appear; stop if drug-induced liver injury is suspected
Long-term effects	Fracture (long-term or multiple daily dosing); B12 deficiency (>3 years); fundic gland polyps; cutaneous or systemic lupus	Review indication; stop for lupus

Overdose & Toxicity Management

Signs: Experience above 240 mg is limited. No specific toxidrome is described
Management: Supportive care. There is no antidote
Extracorporeal removal: Hemodialysis does not remove it

Monitoring

Parameter	When / How Often	Target / Act If
Clinical: GI bleeding	Continuously during transport; with vitals in ED/ICU	New hematemesis, melena, HR rise or SBP fall: escalate for resuscitation and repeat endoscopy
Clinical: stools and skin	Daily	New watery diarrhea: C. difficile testing. Blistering or mucosal rash: stop
Laboratory: hemoglobin	Serial in GI bleeding (CBC)	Hgb <7 g/dL (<8 g/dL with cardiovascular disease): transfuse per protocol
Laboratory: renal function	Baseline and periodically on prolonged therapy	Unexplained creatinine rise: stop, evaluate for interstitial nephritis
Laboratory: magnesium	Before and periodically during prolonged use; sooner with digoxin or diuretics. Pre-existing hypocalcemia risk (e.g. hypoparathyroidism): Mg²⁺ and Ca²⁺ at baseline and periodically	Low Mg²⁺: replace; check K⁺ and Ca²⁺; consider stopping the PPI, including for refractory hypocalcemia
Laboratory: INR	When starting or stopping with warfarin	INR rise or bleeding: adjust warfarin
Medication review	Daily in ICU; at every transfer and discharge	No ongoing indication: stop (prophylaxis is a common carry-over)

Interactions & Compatibility

Clinically Significant Interactions

Drug / Class	Effect	What To Do
Rilpivirine	Much lower rilpivirine levels; virologic failure	Contraindicated
Nelfinavir	Reduced nelfinavir exposure; loss of antiviral effect and resistance	Avoid
Atazanavir	Reduced atazanavir exposure	Follow the atazanavir label (PPI use limited by regimen and treatment history, with dose and timing limits); consult the HIV pharmacist
Saquinavir	Increased saquinavir exposure; possible toxicity	Monitor for saquinavir toxicity; follow the saquinavir label
Other antiretrovirals	Many have no clinically relevant interaction	Check the specific drug label or ask the HIV pharmacist
Warfarin	Reports of increased INR and bleeding	Monitor INR when starting or stopping
High-dose methotrexate	Higher, prolonged methotrexate levels	Consider holding the PPI; monitor levels
pH-dependent drugs (ketoconazole, itraconazole, erlotinib, dasatinib, nilotinib, iron salts, mycophenolate mofetil)	Reduced absorption	Avoid or monitor response; caution with mycophenolate in transplant patients
Clopidogrel	No clinically important effect with pantoprazole	Preferred over omeprazole or esomeprazole
Lab tests (urine THC, chromogranin A)	False-positive THC screen; falsely high chromogranin A	Confirm positive urine drug screens; stop the PPI 14 days before chromogranin A testing

IV Compatibility

Diluents: 0.9% sodium chloride for reconstitution; D5W or NS for dilution and at the Y-site
Incompatible: midazolam at the Y-site; may be incompatible with zinc-containing products
Line: dedicated line or flushed Y-site; stop if precipitate or discoloration appears
Verify with an institutional compatibility resource.

Special Populations

Pediatrics: IV is labeled from 3 months and oral from 5 years, for erosive esophagitis. See the Pediatric Dosing table. Don't reach for acid suppression for crying or regurgitation in otherwise healthy infants.
Neonates: not established below 3 months.
Pregnancy: Observational data have not shown an association with major malformations or other adverse outcomes. The label reports altered bone development in rat pups exposed in utero and through milk. It advises counselling on potential fetal risk. Use it when clinically indicated, such as for GI bleeding
Lactation: Milk levels are very low, about 0.14% of the maternal weight-adjusted dose in one lactating patient. Milk measured 24–36 mcg/L at 2–4 hr and was undetectable by 6 hr (label section 8.2). No infant effects have been reported.
Older Adults: No dose adjustment. Healing and adverse-reaction rates in trials matched younger adults. Fracture, C. difficile, hypomagnesemia and B12 risks climb with long-term use. Use the lowest dose and shortest appropriate course, and review the indication at every transfer. AGS Beers 2023 (strong recommendation): avoid scheduled PPI use for more than 8 weeks unless the patient is high-risk (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment. PPIs carry C. difficile, pneumonia, bone loss and fracture risks.
Renal Impairment: No adjustment, including on dialysis. Hemodialysis does not remove pantoprazole.
Hepatic Impairment: No labeled adjustment. The half-life rises to 7–9 hr and AUC 5- to 7-fold. Oral doses above 40 mg/day have not been studied in hepatic impairment, and neither have interactions at high, more-than-once-daily doses. The high-dose ulcer-bleed regimens (about 272 mg in the first 24 hr with an 80 mg bolus, then 8 mg/hr) therefore rest on guidelines beyond studied labeling.
Obesity / Dosing Weight: Adult doses are fixed. Children are dosed by actual body weight.

Field & Transport Considerations

Scope: Critical care transport, flight and interfacility RN/paramedic crews maintain infusions started at the sending facility. It is not a routine EMS drug. Scope varies by state and agency protocol.
Storage & Stability: Vials stay at room temperature, protected from light. A reconstituted vial awaiting dilution is good for 6 hr. A mixed bag must finish within 24 hr of reconstitution, so confirm the mix time.
Infusions in Transport: run it on a pump with a drug library, through a dedicated line or a Y-site with only D5W or NS. Sedation drips are a mix-up risk. Never piggyback it onto midazolam.
Handoff Essentials: Say the bolus time, the infusion start (the 72-hr clock), the current rate, endoscopy findings and hemostasis, and the last Hgb and transfusions given.

Clinical Pearls

A PPI Does Not Stop Bleeding: With hematemesis or melena and shock, resuscitation and early endoscopy are what save lives. Pantoprazole helps a clot hold after hemostasis. It never replaces blood, airway protection or the endoscopist.

Midazolam Y-Site Trap: Pantoprazole is incompatible with midazolam at the Y-site. In a ventilated patient running several infusions, give it through its own line or a Y-site carrying only D5W or NS.

Exam Discriminator, Upper GI Bleeding:

Peptic ulcer with high-risk stigmata after endoscopic therapy: high-dose PPI for 3 days
Suspected varices: octreotide, antibiotics and banding first
Transfusion threshold: Hgb 7 g/dL (8 g/dL with cardiovascular disease)

Who Needs Prophylaxis: SCCM/ASHP 2024 lists coagulopathy, shock and chronic liver disease. Ventilation alone is not on that list. They also suggest prophylaxis for neurocritical care adults, and they rate a low-dose PPI or H2RA as equal first-line options. For adults with sepsis or septic shock and GI-bleeding risk factors, Surviving Sepsis Campaign 2026 suggests a PPI (conditional, moderate certainty). When a PPI is not available, an H2RA is a reasonable alternative. In the REVISE trial of ventilated adults, pantoprazole cut clinically important upper GI bleeding from 3.5% to 1.0%. Mortality, pneumonia and C. difficile rates did not change. Enteral nutrition probably lowers stress-ulcer bleeding risk. Feeding alone does not replace prophylaxis while risk factors persist.

Switch to Oral Early: Oral bioavailability is about 77%. 40 mg IV and 40 mg PO once daily give comparable acid suppression, so the dose stays the same. Once the gut works, switch to oral therapy: granules in apple juice through a tube, never crushed tablets. That also avoids thrombophlebitis and EDTA exposure.

Pharmacology

Mechanism of Action

It is a prodrug. It concentrates in the acidic parietal-cell canaliculus, where it converts to an active sulfenamide
It binds the H⁺/K⁺-ATPase (proton pump) covalently and blocks the final step of acid secretion, basal and stimulated
The binding is irreversible, so the effect outlasts the 1-hr half-life. Acid secretion returns only as new pumps are made
It only works on active pumps, so the effect builds over several days of daily dosing

Pharmacokinetics

Route	Onset	Peak	Duration
IV	15–30 min	About 90% inhibition of stimulated acid output at 4 hr (40 mg)	24 hr
PO (delayed-release tablet)	About 51% acid inhibition at 2.5 hr after the first dose	Plasma peak 2.5 hr; about 85% inhibition after 7 days of daily dosing	24 hr

Half-life: about 1 hr
Metabolism: hepatic, mainly CYP2C19 (demethylation, then sulfation) with minor CYP3A4; no active metabolites. Poor CYP2C19 metabolizers (about 3% of White and Black, 17–23% of Asian patients) need no adult adjustment
Elimination: about 71% in urine and 18% in feces as metabolites; no unchanged drug in urine
Protein binding / Vd: about 98%, mainly albumin; Vd 11–23.6 L

Names & Classification

Generic Name: Pantoprazole sodium
Brand Names: Protonix (delayed-release tablets and oral suspension), Protonix I.V.; multiple generics
Pharmacologic Class: Proton pump inhibitor (substituted benzimidazole)
Therapeutic Class: Gastric acid suppressant; antiulcer agent
Controlled Substance: Not controlled
ISMP High-Alert: No
Look-Alike / Sound-Alike: Protonix / protamine; Protonix / Lotronex (alosetron)

References

Wyeth Pharmaceuticals LLC (Pfizer). (2025). Protonix I.V. (pantoprazole sodium) for injection: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f39b3e7d-39d2-4c8a-9974-4ab885241880
Wyeth Pharmaceuticals LLC (Pfizer). (2026). Protonix (pantoprazole sodium) delayed-release tablets and delayed-release oral suspension: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=08098cb2-c048-4640-f387-6beec4a38936
Laine, L., Barkun, A. N., Saltzman, J. R., Martel, M., & Leontiadis, G. I. (2021). ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. American Journal of Gastroenterology, 116(5), 899–917. https://doi.org/10.14309/ajg.0000000000001245
Gralnek, I. M., Morris, J., Laursen, S. B., et al. (2026). Endoscopic diagnosis and management of peptic ulcer bleeding: European Society of Gastrointestinal Endoscopy (ESGE) guideline, update 2026. Endoscopy, 58(8), 899–924. https://doi.org/10.1055/a-2863-8314
MacLaren, R., Dionne, J. C., Granholm, A., et al. (2024). Society of Critical Care Medicine and American Society of Health-System Pharmacists guideline for the prevention of stress-related gastrointestinal bleeding in critically ill adults. Critical Care Medicine, 52(8), e421–e430. https://doi.org/10.1097/CCM.0000000000006330
Cook, D., Deane, A., Lauzier, F., et al., for the REVISE Investigators. (2024). Stress ulcer prophylaxis during invasive mechanical ventilation. New England Journal of Medicine, 391(1), 9–20. https://doi.org/10.1056/NEJMoa2404245
Prescott, H. C., Antonelli, M., Alhazzani, W., et al. (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine, 54(4), 725–812. https://doi.org/10.1097/CCM.0000000000007075
Rosen, R., Vandenplas, Y., Singendonk, M., et al. (2018). Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of NASPGHAN and ESPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 66(3), 516–554. https://doi.org/10.1097/MPG.0000000000001889
Wang, Y., Parpia, S., Ge, L., et al. (2024). Proton-pump inhibitors to prevent gastrointestinal bleeding: An updated meta-analysis. NEJM Evidence, 3(7), EVIDoa2400134. https://doi.org/10.1056/EVIDoa2400134
2023 American Geriatrics Society Beers Criteria® Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372

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Pantoprazole (Protonix)