- Approval Id
- d83fcebdad6c5873
- Drug Approval Emc Name
- Pantoprazole 40 mg gastro-resistant tablets
- Drug Name
- Pantoprazole 40 mg gastro-resistant tablets
- Company Name
- Krka UK Ltd
- Company Address
- KRKA UK Ltd, Thames House, Waterside Drive, Langley, Slough, SL3 6EZ, UK
- Company Website
- //www.krka.co.uk
- Company Telephone
- +44 (0)207 164 6156
- Company Medical Info Direct Line
- +44 (0)7572 410 233
- Company Medical Info Email
- info.uk@krka.biz
- Company Customer Care Direct Line
- +44 (0)7894 980 624
- Atc Code
- A02BC02
- Legal Category
- Prescription only medicine
- Authorisation Holder
- KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia
- Authorisation Number
- PL 01656/0023
- Authorisation Date
- 21/09/2007 / 30/04/2010
- Instruction Authorisation Holder
- KRKA, d.d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia
- Instruction Authorisation Number
- PL 01656/0023
- Instruction Authorisation Date
- 21/09/2007 / 30/04/2010
- Instruction Composition
- Each gastro-resistant tablet contains 40 mg pantoprazole (as pantoprazole sodium sesquihydrate).
Excipient \*\*with known effect\*\*:
- sorbitol: 36 mg/tablet
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Gastro-resistant tablet.
A light brownish yellow, oval, slightly biconvex tablet.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
\*Adults and adolescents 12 years of age and above\*
Reflux oesophagitis.
\*Adults\*
- Eradication of Helicobacter \*pylori\* (\*H. pylori\*) in combination with appropriate antibiotic therapy in patients with \*H. pylori\* associated ulcers.
- Gastric and duodenal ulcer.
- Zollinger-Ellison-Syndrome and other pathological hypersecretory conditions.4.2 Posology and method of administration
\*\*Posology\*\*
\*Adults and adolescents 12 years of age and above\*
\*\*Reflux oesophagitis\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A 4-week period is usually required for the treatment of reflux oesophagitis. If this is not sufficient, healing will usually be achieved within a further 4 weeks.
\*Adults\*
\*\*Eradication of\*\* \*\*\*H. pylori\*\*\* \*\*in combination with two appropriate antibiotics\*\*
In H. pylori positive patients with gastric and duodenal ulcers, eradication of the germ by a combination therapy should be achieved. Considerations should be given to official local guidance (e.g. national recommendations) regarding bacterial resistance and the appropriate use and prescription of antibacterial agents. Depending upon the resistance pattern, the following combinations can be recommended for the eradication of \*H. pylori\*:
a) twice daily one tablet Pantoprazole
+ twice daily 1000 mg amoxicillin
+ twice daily 500 mg clarithromycin
b) twice daily one tablet Pantoprazole
+ twice daily 400 - 500 mg metronidazole (or 500 mg tinidazole)
+ twice daily 250 - 500 mg clarithromycin
c) twice daily one tablet Pantoprazole
+ twice daily 1000 mg amoxicillin
+ twice daily 400 - 500 mg metronidazole (or 500 mg tinidazole)
In combination therapy for eradication of \*H. pylori\* infection, the second Pantoprazole tablet should be taken 1 hour before the evening meal. The combination therapy is implemented for 7 days in general and can be prolonged for a further 7 days to a total duration of up to two weeks. If, to ensure healing of the ulcers, further treatment with pantoprazole is indicated, the dose recommendations for duodenal and gastric ulcers should be considered.
If combination therapy is not an option, e.g. if the patient has tested negative for \*H. pylori\*, the following dose guidelines apply for Pantoprazole monotherapy:
\*\*Treatment of gastric ulcer\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A 4-week period is usually required for the treatment of gastric ulcers. If this is not sufficient, healing will usually be achieved within a further 4 weeks.
\*\*Treatment of duodenal ulcer\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A duodenal ulcer generally heals within 2 weeks. If a 2-week period of treatment is not sufficient, healing will be achieved in almost all cases within a further 2 weeks.
\*\*Zollinger-Ellison-\*\*Syndrome \*\*and other pathological hypersecretory conditions\*\*
For the long-term management of Zollinger-Ellison-Syndrome and other pathological hypersecretory conditions patients should start their treatment with a daily dose of 80 mg (2 tablets of Pantoprazole 40 mg). Thereafter, the dose can be titrated up or down as needed using measurements of gastric acid secretion to guide. With doses above 80 mg daily, the dose should be divided and given twice daily. A temporary increase of the dose above 160 mg pantoprazole is possible but should not be applied longer than required for adequate acid control.
Treatment duration in Zollinger-Ellison syndrome and other pathological hypersecretory conditions is not limited and should be adapted according to clinical needs.
\*\*\*Special populations\*\*\*
\*\*Elderly\*\*
No dose adjustment is necessary in the elderly.
\*\*Hepatic impairment\*\*
A daily dose of 20 mg pantoprazole (1 tablet of 20 mg pantoprazole) should not be exceeded in patients with severe liver impairment. Pantoprazole must not be used in combination treatment for eradication of \*H. pylori\* in patients with moderate to severe hepatic dysfunction since currently no data are available on the efficacy and safety of Pantoprazole in combination treatment of these patients (see section 4.4).
\*\*Renal impairment\*\*
No dose adjustment is necessary in patients with impaired renal function. Pantoprazole must not be used in combination treatment for eradication of \*H. pylori\* in patients with impaired renal function since currently no data are available on the efficacy and safety of Pantoprazole in combination treatment for these patients.
\*Paediatric\* population
\*Children below\* 12 \*years of age\*
Pantoprazole is not recommended for use in children below 12 years of age due to limited data on safety and efficacy in this age group.
\*\*Method of administration\*\*
Tablets should not be chewed or crushed, and should be swallowed whole 1 hour before a meal with some water.4.3 Contraindications
Hypersensitivity to the active substance, substituted benzimidazoles, sorbitol or to any of the excipients listed in section 6.1.4.4 Special warnings and precautions for use
\*Hepatic impairment\*
In patients with severe liver impairment, the liver enzymes should be monitored regularly during treatment with pantoprazole, particularly on long-term use. In the case of a rise of the liver enzymes, the treatment should be discontinued (see section 4.2).
\*Combination therapy\*
In the case of combination therapy, the summaries of product characteristics of the respective medicinal products should be observed.
\*\*Gastric malignancy\*\*
Symptomatic response to pantoprazole may mask the symptoms of gastric malignancy and may delay diagnosis. In the presence of any alarm symptom (e. g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis, anaemia or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded.
Further investigation is to be considered if symptoms persist despite adequate treatment.
\*\*Co-administration with HIV protease inhibitors\*\*
Co-administration of pantoprazole is not recommended with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir, due to significant reduction in their bioavailability (see section 4.5).
\*\*Influence on vitamin B12 absorption\*\*
In patients with Zollinger-Ellison syndrome and other pathological hypersecretory conditions requiring long-term treatment, pantoprazole, as all acid-blocking medicines, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or achlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy or if respective clinical symptoms are observed.
\*\*Long term treatment\*\*
In long-term treatment, especially when exceeding a treatment period of 1 year, patients should be kept under regular surveillance.
\*\*Gastrointestinal infections caused by bacteria\*\*
Treatment with Pantoprazole may lead to a slightly increased risk of gastrointestinal infections caused by bacteria such as \*Salmonella and Campylobacter\* and C. \*difficile\*.
\*\*Hypomagnesaemia\*\*
Severe hypomagnesaemia has been rarely reported in patients treated with proton pump inhibitors (PPIs) like pantoprazole for at least three months, and in most cases for a year. Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur but they may begin insidiously and be overlooked. Hypomagnesaemia may lead to hypocalcaemia and/or hypokalaemia (see section 4.8). In most affected patients, hypomagnesaemia (and hypomagnesaemia associated hypocalcaemia and/or hypokalaemia) improved after magnesium replacement and discontinuation of the PPI.
For patients expected to be on prolonged treatment or who take PPIs with digoxin or drugs that may cause hypomagnesaemia (e.g., diuretics), health care professionals should consider measuring magnesium levels before starting PPI treatment and periodically during treatment.
\*\*Bone fractures\*\*
Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be due to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium.
\*\*Subacute cutaneous lupus erythematosus (SCLE)\*\*
Proton pump inhibitors are associated with very infrequent cases of SCLE. If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care professional should consider stopping Pantoprazole. SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors.
\*\*Interference with laboratory tests\*\*
Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours. To avoid this interference, Pantoprazole treatment should be stopped for at least 5 days before CgA measurements (see section 5.1). If CgA and gastrin levels have not returned to reference range after initial measurement, measurements should be repeated 14 days after cessation of proton pump inhibitor treatment.
\*\*Pantoprazole 40 mg contains sorbitol and sodium.\*\*
This medicine contains 36 mg sorbitol in each tablet.
The additive effect of concomitantly administered products containing sorbitol (or fructose) and dietary intake of sorbitol (or fructose) should be taken into account.
The content of sorbitol in medicinal products for oral use may affect the bioavailability of other medicinal products for oral use administered concomitantly.
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Medicinal products with pH-dependent absorption pharmacokinetics\*\*
Because of profound and long lasting inhibition of gastric acid secretion, pantoprazole may interfere with the absorption of other medicinal products where gastric pH is an important determinant of oral bioavailability, e.g. some azole antifungals such as ketoconazole, itraconazole, posaconazole and other medicine such as erlotinib.
\*\*HIV protease inhibitors\*\*
Co-administration of pantoprazole is not recommended with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir due to significant reduction in their bioavailability (see section 4.4).
If the combination of HIV protease inhibitors with a proton pump inhibitor is judged unavoidable, close clinical monitoring (e.g. virus load) is recommended. A pantoprazole dose of 20 mg per day should not be exceeded. Dosage of the HIV protease inhibitors may need to be adjusted.
\*\*Coumarin anticoagulants (phenprocoumon or warfarin)\*\*
Co-administration of pantoprazole with warfarin or phenprocoumon did not affect the pharmacokinetics of warfarin, phenprocoumon or INR. However, there have been reports of increased INR and prothrombin time in patients receiving PPIs and warfarin or phenprocoumon concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding, and even death. Patients treated with pantoprazole and warfarin or phenprocoumon may need to be monitored for increase in INR and prothrombin time.
\*\*Methotrexate\*\*
Concomitant use of high dose methotrexate (e.g. 300 mg) and proton-pump inhibitors has been reported to increase methotrexate levels in some patients. Therefore in settings where high-dose methotrexate is used, for example cancer and psoriasis, a temporary withdrawal of pantoprazole may need to be considered.
\*\*Other interactions studies\*\*
Pantoprazole is extensively metabolized in the liver via the cytochrome P450 enzyme system. The main metabolic pathway is demethylation by CYP2C19 and other metabolic pathways include oxidation by CYP3A4.
Interaction studies with drugs also metabolized with these pathways, like carbamazepine, diazepam, glibenclamide, nifedipine, and an oral contraceptive containing levonorgestrel and ethinyl oestradiol did not reveal clinically significant interactions.
An interaction of pantoprazole with other medicinal products or compounds, which are metabolized using the same enzyme system, cannot be excluded.
Results from a range of interaction studies demonstrate that pantoprazole does not affect the metabolism of active substances metabolised by CYP1A2 (such as caffeine, theophylline), CYP2C9 (such as piroxicam, diclofenac, naproxen), CYP2D6 (such as metoprolol), CYP2E1 (such as ethanol) or does not interfere with p-glycoprotein related absorption of digoxin.
There were no interactions with concomitantly administered antacids.
Interaction studies have also been performed administering pantoprazole concomitantly with the respective antibiotics (clarithromycin, metronidazole, amoxicillin). No clinically relevant interactions were found.
Medicinal products that inhibit or induce CYP2C19:
Inhibitors of CYP2C19 such as fluvoxamine could increase the systemic exposure of pantoprazole. A dose reduction may be considered for patients treated long-term with high doses of pantoprazole, or those with hepatic impairment.
Enzyme inducers affecting CYP2C19 and CYP3A4 such as rifampicin and St John´s wort (Hypericum perforatum) may reduce the plasma concentrations of PPIs that are metabolized through these enzyme systems.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
A moderate amount of data on pregnant women (between 300-1000 pregnancy outcomes) indicate no malformative or feto/ neonatal toxicity of pantoprazole.
Animal studies have shown reproductive toxicity (see section 5.3).
As a precautionary measure, it is preferable to avoid the use of Pantoprazole during pregnancy.
\*\*Breastfeeding\*\*
Animal studies have shown excretion of pantoprazole in breast milk. There is insufficient information on the excretion of pantoprazole in human milk but excretion into human milk has been reported. A risk to the newborns/infants cannot be excluded. Therefore, a decision on whether to discontinue breast-feeding or to discontinue/abstain from therapy with Pantoprazole taking into account the benefit of breast-feeding for the child, and the benefit of Pantoprazole therapy for the woman.
\*\*Fertility\*\*
There was no evidence of impaired fertility following the administration of pantoprazole in animal studies (see section 5.3).4.7 Effects on ability to drive and use machines
Pantoprazole has no or negligible influence on the ability to drive and use machines.
Adverse drug reactions such as dizziness and visual disturbances may occur (see section 4.8). If affected, patients should not drive or operate machines.4.8 Undesirable effects
Approximately 5 % of patients can be expected to experience adverse drug reactions (ADRs).
The table below lists adverse reactions reported with pantoprazole, ranked under the following frequency classification:
- Very common (≥ 1/10)
- Common (≥ 1/100 to < 1/10)
- Uncommon (≥ 1/1,000 to < 1/100)
- Rare (≥ 1/10,000 to < 1/1,000)
- Very rare (< 1/10,000)
- Not known (cannot be estimated from the available data)
For all adverse reactions reported from post-marketing experience, it is not possible to apply any Adverse Reaction frequency and therefore they are mentioned with a “not known” frequency.
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
\*\*Tabulated list of adverse reactions\*\*
Table 1. Adverse reactions with pantoprazole in clinical trials and post-marketing experience
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*Frequency\*\* | \*\*Common\*\* | \*\*Uncommon\*\* | \*\*Rare\*\* | \*\*Very rare\*\* | \*\*Not known\*\* |
| \*\*System Organ Class\*\* |
| Blood and lymphatic system disorders | | | Agranulocytosis | Thrombocytopenia; Leucopenia, Pancytopennia | |
| Immune system disorders | | | Hypersenstivity (including anaphylactic reactions and anaphylactic shock) | | |
| Metabolism and nutrition disorders | | | Hyperlipidaemias and lipid increases (triglycerides, cholesterol); Weight changes | | Hyponatraemia; Hypomagnesaemia (\*see section 4.4)\* Hypocalcaemia1 Hypokalaemia1 |
| Psychiatric disorders | | Sleep disorders | Depression (and all aggravations) | Disorientation (and all aggravations) | Hallucination; Confusion (especially in pre-disposed patients, as well as the aggravation of these symptoms in case of pre-existence) |
| Nervous system disorders | | Headache; Dizziness | Taste disorders | | Paraesthesia |
| Eye disorders | | | Disturbances in vision / blurred vision | | |
| Gastrointestinal disorders | Fundic gland polyps (benign) | Diarrhoea; Nausea / vomiting; Abdominal distension and bloating; Constipation; Dry mouth; Abdominal pain and discomfort | | | Microscopic colitis |
| Hepatobiliary disorders | | Liver enzymes increased (transaminases, γ-GT) | Bilirubin increased | | Hepatocellular injury; Jaundice; Hepatocellular failure |
| Skin and sub-cutaneous tissue disorders | | Rash / exanthema / eruption; Pruritus | Urticaria; Angioedema | | Stevens-Johnson syndrome; Lyell syndrome; Erythema multiforme; Photosensitivity; Subacute cutaneous lupus erythematosus (see section 4.4); Drug reaction with eosinophilia and systemic symptoms (DRESS) |
| Musculoskeletal, connective tissue disorders | | Fracture of the hip, wrist or spine (\*see section 4.4\*) | Arthralgia; Myalgia | | Muscle spasm2 |
| Renal and urinary disorders | | | | | Tubulointerstitial nephritis (TIN) (with possible progression to renal failure) |
| Reproductive system and breast disorders | | | Gynaecomastia | | |
| General disorders and administration site conditions | | Asthenia, fatigue and malaise | Body temperature increased; Oedema peripheral | | |
1.Hypocalcaemia and/or hypokalaemia may be related to the occurrence of hypomagnesaemia (see section 4.4)
2 Muscle spasm as a consequence of electrolyte disturbance
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme, Website: https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
\*\*Symptoms\*\*
There are no known symptoms of overdose in man.
Systemic exposure with up to 240 mg administered intravenously over 2 minutes were well tolerated.
\*\*Management\*\*
As pantoprazole is extensively protein bound, it is not readily dialysable.
In the case of overdose with clinical signs of intoxication, apart from symptomatic and supportive treatment, no specific therapeutic recommendations can be made.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Proton pump inhibitors; ATC code: A02BC02
\*\*\*Mechanism of action\*\*\*
Pantoprazole is a substituted benzimidazole which inhibits the secretion of hydrochloric acid in the stomach by specific blockade of the proton pumps of the parietal cells.
Pantoprazole is converted to its active form in the acidic environment in the parietal cells where it inhibits the H+, K+-ATPase enzyme, i.e. the final stage in the production of hydrochloric acid in the stomach. The inhibition is dose-dependent and affects both basal and stimulated acid secretion. In most patients, freedom from symptoms is achieved within 2 weeks. As with other proton pump inhibitors and H2 receptor inhibitors, treatment with pantoprazole reduces acidity in the stomach and thereby increases gastrin in proportion to the reduction in acidity. The increase in gastrin is reversible. Since pantoprazole binds to the enzyme distal to the cell receptor level, it can inhibit hydrochloric acid secretion independently of stimulation by other substances (acetylcholine, histamine, gastrin). The effect is the same whether the product is given orally or intravenously.
\*\*Pharmacodynamic effects\*\*
The fasting gastrin values increase under pantoprazole. On short-term use, in most cases they do not exceed the upper limit of normal. During long-term treatment, gastrin levels double in most cases. An excessive increase, however, occurs only in isolated cases. As a result, a mild to moderate increase in the number of specific endocrine (ECL) cells in the stomach is observed in a minority of cases during long-term treatment (simple to adenomatoid hyperplasia). However, according to the studies conducted so far, the formation of carcinoid precursors (atypical hyperplasia) or gastric carcinoids as were found in animal experiments (see section 5.3) have not been observed in humans.
During treatment with antisecretory medicinal products, serum gastrin increases in response to the decreased acid secretion. Also CgA increases due to decreased gastric acidity. The increased CgA level may interfere with investigations for neuroendocrine tumours.
Available published evidence suggests that proton pump inhibitors should be discontinued between 5 days and 2 weeks prior to CgA measurements. This is to allow CgA levels that might be spuriously elevated following PPI treatment to return to reference range.
An influence of a long term treatment with pantoprazole exceeding one year cannot be completely ruled out on endocrine parameters of the thyroid according to results in animal studies.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Pantoprazole is rapidly absorbed and the maximal plasma concentration is achieved even after one single 40 mg oral dose. On average at about 2.5 h p.a. the maximum serum concentrations of about 2 - 3 μg/ml are achieved, and these values remain constant after multiple administration.
Pharmacokinetics do not vary after single or repeated administration. In the dose range of 10 to 80 mg, the plasma kinetics of pantoprazole are linear after both oral and intravenous administration.
The absolute bioavailability from the tablet was found to be about 77 %. Concomitant intake of food had no influence on AUC, maximum serum concentration and thus bioavailability. Only the variability of the lag-time will be increased by concomitant food intake.
\*\*Distribution\*\*
Pantoprazole's serum protein binding is about 98 %. Volume of distribution is about 0.15 l/kg.
\*\*Biotransformation\*\*
The substance is almost exclusively metabolized in the liver. The main metabolic pathway is demethylation by CYP2C19 with subsequent sulphate conjugation, other metabolic pathway include oxidation by CYP3A4.
\*\*Elimination\*\*
Terminal half-life is about 1 hour and clearance is about 0.1 l/h/kg. There were a few cases of subjects with delayed elimination. Because of the specific binding of pantoprazole to the proton pumps of the parietal cell the elimination half-life does not correlate with the much longer duration of action (inhibition of acid secretion).
Renal elimination represents the major route of excretion (about 80 %) for the metabolites of pantoprazole, the rest is excreted with the faeces. The main metabolite in both the serum and urine is desmethylpantoprazole which is conjugated with sulphate. The half-life of the main metabolite (about 1.5 hours) is not much longer than that of pantoprazole.
\*Special populations\*
\*\*Renal impairment\*\*
No dose reduction is recommended when pantoprazole is administered to patients with impaired renal function (including dialysis patients). As with healthy subjects, pantoprazole's half-life is short. Only very small amounts of pantoprazole are dialyzed. Although the main metabolite has a moderately delayed half-life (2 - 3 h), excretion is still rapid and thus accumulation does not occur.
\*\*Hepatic impairment\*\*
Although for patients with liver cirrhosis (classes A and B according to Child) the half-life values increased to between 7 and 9 h and the AUC values increased by a factor of 5 - 7, the maximum serum concentration only increased slightly by a factor of 1.5 compared with healthy subjects.
\*\*Elderly\*\*
A slight increase in AUC and Cmax in elderly volunteers compared with younger counterparts is also not clinically relevant.
\*\*Poor metabolisers\*\*
Approximately 3 % of the European population lack a functional CYP2C19 enzyme and are called poor metabolisers. In these individuals the metabolism of pantoprazole is probably mainly catalysed by CYP3A4. After a single-dose administration of 40 mg pantoprazole, the mean area under the plasma concentration-time curve was approximately 6 times higher in poor metabolisers than in subjects having a functional CYP2C19 enzyme (extensive metabolisers). Mean peak plasma concentrations were increased by about 60 %. These findings have no implications for the posology of pantoprazole.
\*\*Paediatric population\*\*
Following administration of single oral doses of 20 or 40 mg pantoprazole to children aged 5 - 16 years AUC and Cmax were in the range of corresponding values in adults.
Following administration of single i.v. doses of 0.8 or 1.6 mg/kg pantoprazole to children aged 2 - 16 years there was no significant association between pantoprazole clearance and age or weight. AUC and volume of distribution were in accordance with data from adults.5.3 Preclinical safety data
Preclinical data reveal no special hazard to humans based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity.
In the two-year carcinogenicity studies in rats neuroendocrine neoplasms were found. In addition, squamous cell papillomas were found in the forestomach of rats. The mechanism leading to the formation of gastric carcinoids by substituted benzimidazoles has been carefully investigated and allows the conclusion that it is a secondary reaction to the massively elevated serum gastrin levels occurring in the rat during chronic high-dose treatment. In the two-year rodent studies an increased number of liver tumors was observed in rats and in female mice and was interpreted as being due to pantoprazole's high metabolic rate in the liver.
A slight increase of neoplastic changes of the thyroid was observed in the group of rats receiving the highest dose (200 mg/kg). The occurrence of these neoplasms is associated with the pantoprazole-induced changes in the breakdown of thyroxine in the rat liver. As the therapeutic dose in man is low, no harmful effects on the thyroid glands are expected.
In a peri-postnatal rat reproduction study designed to assess bone development, signs of offspring toxicity (mortality, lower mean body weight, lower mean body weight gain and reduced bone growth) were observed at exposures (Cmax) approximately 2x the human clinical exposure. By the end of the recovery phase, bone parameters were similar across groups and body weights were also trending toward reversibility after a drug-free recovery period. The increased mortality has only been reported in pre-weaning rat pups (up to 21 days age) which is estimated to correspond to infants up to the age of 2 years old. The relevance of this finding to the paediatric population is unclear. A previous peri-postnatal study in rats at slightly lower doses found no adverse effects at 3 mg/kg compared with a low dose of 5 mg/kg in this study.
Investigations revealed no evidence of impaired fertility or teratogenic effects.
Penetration of the placenta was investigated in the rat and was found to increase with advanced gestation. As a result, concentration of pantoprazole in the foetus is increased shortly before birth.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
\*\*Tablet\*\* \*\*\*core\*\*\*
Mannitol
Crospovidone (type A, type B)
Sodium carbonate
Sorbitol (E420)
Calcium stearate
\*\*Film\*\* \*\*\*coating\*\*\*
Hypromellose
Povidone (K25)
Titanium dioxide (E171)
Iron oxide, yellow (E172)
Propylene glycol
Methacrylic acid - ethyl acrylate copolymer
Sodium laurilsulfate
Polysorbate 80
Macrogol 6000
Talc6.2 Incompatibilities
Not applicable.6.3 Shelf life
5 years
\*\*\*HDPE container:\*\*\*
After first opening of the container, the product should be used within 3 months.6.4 Special precautions for storage
This medicinal product does not require any special temperature storage conditions.
Blister pack: Store in the original package in order to protect from moisture.
Container: Keep the container tightly closed in order to protect from moisture.6.5 Nature and contents of container
Blister pack (OPA/Aluminium/PVC film and aluminium foil) in a carton box.
Pack-sizes of 7, 14, 15, 20, 28, 30, 50, 50 x 1, 56, 60, 84, 90, 98, 100, 100 x 1, 112 and 140 gastro-resistant tablets.
HDPE containers with a silica gel desiccant in a tamper evident PP screw-cap.
Pack-size of 100 and 250 gastro-resistant tablets.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements.
- Instruction Content
- ## Composition
Each gastro-resistant tablet contains 40 mg pantoprazole (as pantoprazole sodium sesquihydrate).
Excipient \*\*with known effect\*\*:
- sorbitol: 36 mg/tablet
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Gastro-resistant tablet.
A light brownish yellow, oval, slightly biconvex tablet.
## Clinical Particulars
4.1 Therapeutic indications
\*Adults and adolescents 12 years of age and above\*
Reflux oesophagitis.
\*Adults\*
- Eradication of Helicobacter \*pylori\* (\*H. pylori\*) in combination with appropriate antibiotic therapy in patients with \*H. pylori\* associated ulcers.
- Gastric and duodenal ulcer.
- Zollinger-Ellison-Syndrome and other pathological hypersecretory conditions.4.2 Posology and method of administration
\*\*Posology\*\*
\*Adults and adolescents 12 years of age and above\*
\*\*Reflux oesophagitis\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A 4-week period is usually required for the treatment of reflux oesophagitis. If this is not sufficient, healing will usually be achieved within a further 4 weeks.
\*Adults\*
\*\*Eradication of\*\* \*\*\*H. pylori\*\*\* \*\*in combination with two appropriate antibiotics\*\*
In H. pylori positive patients with gastric and duodenal ulcers, eradication of the germ by a combination therapy should be achieved. Considerations should be given to official local guidance (e.g. national recommendations) regarding bacterial resistance and the appropriate use and prescription of antibacterial agents. Depending upon the resistance pattern, the following combinations can be recommended for the eradication of \*H. pylori\*:
a) twice daily one tablet Pantoprazole
+ twice daily 1000 mg amoxicillin
+ twice daily 500 mg clarithromycin
b) twice daily one tablet Pantoprazole
+ twice daily 400 - 500 mg metronidazole (or 500 mg tinidazole)
+ twice daily 250 - 500 mg clarithromycin
c) twice daily one tablet Pantoprazole
+ twice daily 1000 mg amoxicillin
+ twice daily 400 - 500 mg metronidazole (or 500 mg tinidazole)
In combination therapy for eradication of \*H. pylori\* infection, the second Pantoprazole tablet should be taken 1 hour before the evening meal. The combination therapy is implemented for 7 days in general and can be prolonged for a further 7 days to a total duration of up to two weeks. If, to ensure healing of the ulcers, further treatment with pantoprazole is indicated, the dose recommendations for duodenal and gastric ulcers should be considered.
If combination therapy is not an option, e.g. if the patient has tested negative for \*H. pylori\*, the following dose guidelines apply for Pantoprazole monotherapy:
\*\*Treatment of gastric ulcer\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A 4-week period is usually required for the treatment of gastric ulcers. If this is not sufficient, healing will usually be achieved within a further 4 weeks.
\*\*Treatment of duodenal ulcer\*\*
One tablet of Pantoprazole per day. In individual cases the dose may be doubled (increase to 2 tablets Pantoprazole daily) especially when there has been no response to other treatment. A duodenal ulcer generally heals within 2 weeks. If a 2-week period of treatment is not sufficient, healing will be achieved in almost all cases within a further 2 weeks.
\*\*Zollinger-Ellison-\*\*Syndrome \*\*and other pathological hypersecretory conditions\*\*
For the long-term management of Zollinger-Ellison-Syndrome and other pathological hypersecretory conditions patients should start their treatment with a daily dose of 80 mg (2 tablets of Pantoprazole 40 mg). Thereafter, the dose can be titrated up or down as needed using measurements of gastric acid secretion to guide. With doses above 80 mg daily, the dose should be divided and given twice daily. A temporary increase of the dose above 160 mg pantoprazole is possible but should not be applied longer than required for adequate acid control.
Treatment duration in Zollinger-Ellison syndrome and other pathological hypersecretory conditions is not limited and should be adapted according to clinical needs.
\*\*\*Special populations\*\*\*
\*\*Elderly\*\*
No dose adjustment is necessary in the elderly.
\*\*Hepatic impairment\*\*
A daily dose of 20 mg pantoprazole (1 tablet of 20 mg pantoprazole) should not be exceeded in patients with severe liver impairment. Pantoprazole must not be used in combination treatment for eradication of \*H. pylori\* in patients with moderate to severe hepatic dysfunction since currently no data are available on the efficacy and safety of Pantoprazole in combination treatment of these patients (see section 4.4).
\*\*Renal impairment\*\*
No dose adjustment is necessary in patients with impaired renal function. Pantoprazole must not be used in combination treatment for eradication of \*H. pylori\* in patients with impaired renal function since currently no data are available on the efficacy and safety of Pantoprazole in combination treatment for these patients.
\*Paediatric\* population
\*Children below\* 12 \*years of age\*
Pantoprazole is not recommended for use in children below 12 years of age due to limited data on safety and efficacy in this age group.
\*\*Method of administration\*\*
Tablets should not be chewed or crushed, and should be swallowed whole 1 hour before a meal with some water.4.3 Contraindications
Hypersensitivity to the active substance, substituted benzimidazoles, sorbitol or to any of the excipients listed in section 6.1.4.4 Special warnings and precautions for use
\*Hepatic impairment\*
In patients with severe liver impairment, the liver enzymes should be monitored regularly during treatment with pantoprazole, particularly on long-term use. In the case of a rise of the liver enzymes, the treatment should be discontinued (see section 4.2).
\*Combination therapy\*
In the case of combination therapy, the summaries of product characteristics of the respective medicinal products should be observed.
\*\*Gastric malignancy\*\*
Symptomatic response to pantoprazole may mask the symptoms of gastric malignancy and may delay diagnosis. In the presence of any alarm symptom (e. g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis, anaemia or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded.
Further investigation is to be considered if symptoms persist despite adequate treatment.
\*\*Co-administration with HIV protease inhibitors\*\*
Co-administration of pantoprazole is not recommended with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir, due to significant reduction in their bioavailability (see section 4.5).
\*\*Influence on vitamin B12 absorption\*\*
In patients with Zollinger-Ellison syndrome and other pathological hypersecretory conditions requiring long-term treatment, pantoprazole, as all acid-blocking medicines, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or achlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy or if respective clinical symptoms are observed.
\*\*Long term treatment\*\*
In long-term treatment, especially when exceeding a treatment period of 1 year, patients should be kept under regular surveillance.
\*\*Gastrointestinal infections caused by bacteria\*\*
Treatment with Pantoprazole may lead to a slightly increased risk of gastrointestinal infections caused by bacteria such as \*Salmonella and Campylobacter\* and C. \*difficile\*.
\*\*Hypomagnesaemia\*\*
Severe hypomagnesaemia has been rarely reported in patients treated with proton pump inhibitors (PPIs) like pantoprazole for at least three months, and in most cases for a year. Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur but they may begin insidiously and be overlooked. Hypomagnesaemia may lead to hypocalcaemia and/or hypokalaemia (see section 4.8). In most affected patients, hypomagnesaemia (and hypomagnesaemia associated hypocalcaemia and/or hypokalaemia) improved after magnesium replacement and discontinuation of the PPI.
For patients expected to be on prolonged treatment or who take PPIs with digoxin or drugs that may cause hypomagnesaemia (e.g., diuretics), health care professionals should consider measuring magnesium levels before starting PPI treatment and periodically during treatment.
\*\*Bone fractures\*\*
Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be due to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium.
\*\*Subacute cutaneous lupus erythematosus (SCLE)\*\*
Proton pump inhibitors are associated with very infrequent cases of SCLE. If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care professional should consider stopping Pantoprazole. SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors.
\*\*Interference with laboratory tests\*\*
Increased Chromogranin A (CgA) level may interfere with investigations for neuroendocrine tumours. To avoid this interference, Pantoprazole treatment should be stopped for at least 5 days before CgA measurements (see section 5.1). If CgA and gastrin levels have not returned to reference range after initial measurement, measurements should be repeated 14 days after cessation of proton pump inhibitor treatment.
\*\*Pantoprazole 40 mg contains sorbitol and sodium.\*\*
This medicine contains 36 mg sorbitol in each tablet.
The additive effect of concomitantly administered products containing sorbitol (or fructose) and dietary intake of sorbitol (or fructose) should be taken into account.
The content of sorbitol in medicinal products for oral use may affect the bioavailability of other medicinal products for oral use administered concomitantly.
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Medicinal products with pH-dependent absorption pharmacokinetics\*\*
Because of profound and long lasting inhibition of gastric acid secretion, pantoprazole may interfere with the absorption of other medicinal products where gastric pH is an important determinant of oral bioavailability, e.g. some azole antifungals such as ketoconazole, itraconazole, posaconazole and other medicine such as erlotinib.
\*\*HIV protease inhibitors\*\*
Co-administration of pantoprazole is not recommended with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir due to significant reduction in their bioavailability (see section 4.4).
If the combination of HIV protease inhibitors with a proton pump inhibitor is judged unavoidable, close clinical monitoring (e.g. virus load) is recommended. A pantoprazole dose of 20 mg per day should not be exceeded. Dosage of the HIV protease inhibitors may need to be adjusted.
\*\*Coumarin anticoagulants (phenprocoumon or warfarin)\*\*
Co-administration of pantoprazole with warfarin or phenprocoumon did not affect the pharmacokinetics of warfarin, phenprocoumon or INR. However, there have been reports of increased INR and prothrombin time in patients receiving PPIs and warfarin or phenprocoumon concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding, and even death. Patients treated with pantoprazole and warfarin or phenprocoumon may need to be monitored for increase in INR and prothrombin time.
\*\*Methotrexate\*\*
Concomitant use of high dose methotrexate (e.g. 300 mg) and proton-pump inhibitors has been reported to increase methotrexate levels in some patients. Therefore in settings where high-dose methotrexate is used, for example cancer and psoriasis, a temporary withdrawal of pantoprazole may need to be considered.
\*\*Other interactions studies\*\*
Pantoprazole is extensively metabolized in the liver via the cytochrome P450 enzyme system. The main metabolic pathway is demethylation by CYP2C19 and other metabolic pathways include oxidation by CYP3A4.
Interaction studies with drugs also metabolized with these pathways, like carbamazepine, diazepam, glibenclamide, nifedipine, and an oral contraceptive containing levonorgestrel and ethinyl oestradiol did not reveal clinically significant interactions.
An interaction of pantoprazole with other medicinal products or compounds, which are metabolized using the same enzyme system, cannot be excluded.
Results from a range of interaction studies demonstrate that pantoprazole does not affect the metabolism of active substances metabolised by CYP1A2 (such as caffeine, theophylline), CYP2C9 (such as piroxicam, diclofenac, naproxen), CYP2D6 (such as metoprolol), CYP2E1 (such as ethanol) or does not interfere with p-glycoprotein related absorption of digoxin.
There were no interactions with concomitantly administered antacids.
Interaction studies have also been performed administering pantoprazole concomitantly with the respective antibiotics (clarithromycin, metronidazole, amoxicillin). No clinically relevant interactions were found.
Medicinal products that inhibit or induce CYP2C19:
Inhibitors of CYP2C19 such as fluvoxamine could increase the systemic exposure of pantoprazole. A dose reduction may be considered for patients treated long-term with high doses of pantoprazole, or those with hepatic impairment.
Enzyme inducers affecting CYP2C19 and CYP3A4 such as rifampicin and St John´s wort (Hypericum perforatum) may reduce the plasma concentrations of PPIs that are metabolized through these enzyme systems.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
A moderate amount of data on pregnant women (between 300-1000 pregnancy outcomes) indicate no malformative or feto/ neonatal toxicity of pantoprazole.
Animal studies have shown reproductive toxicity (see section 5.3).
As a precautionary measure, it is preferable to avoid the use of Pantoprazole during pregnancy.
\*\*Breastfeeding\*\*
Animal studies have shown excretion of pantoprazole in breast milk. There is insufficient information on the excretion of pantoprazole in human milk but excretion into human milk has been reported. A risk to the newborns/infants cannot be excluded. Therefore, a decision on whether to discontinue breast-feeding or to discontinue/abstain from therapy with Pantoprazole taking into account the benefit of breast-feeding for the child, and the benefit of Pantoprazole therapy for the woman.
\*\*Fertility\*\*
There was no evidence of impaired fertility following the administration of pantoprazole in animal studies (see section 5.3).4.7 Effects on ability to drive and use machines
Pantoprazole has no or negligible influence on the ability to drive and use machines.
Adverse drug reactions such as dizziness and visual disturbances may occur (see section 4.8). If affected, patients should not drive or operate machines.4.8 Undesirable effects
Approximately 5 % of patients can be expected to experience adverse drug reactions (ADRs).
The table below lists adverse reactions reported with pantoprazole, ranked under the following frequency classification:
- Very common (≥ 1/10)
- Common (≥ 1/100 to < 1/10)
- Uncommon (≥ 1/1,000 to < 1/100)
- Rare (≥ 1/10,000 to < 1/1,000)
- Very rare (< 1/10,000)
- Not known (cannot be estimated from the available data)
For all adverse reactions reported from post-marketing experience, it is not possible to apply any Adverse Reaction frequency and therefore they are mentioned with a “not known” frequency.
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
\*\*Tabulated list of adverse reactions\*\*
Table 1. Adverse reactions with pantoprazole in clinical trials and post-marketing experience
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*Frequency\*\* | \*\*Common\*\* | \*\*Uncommon\*\* | \*\*Rare\*\* | \*\*Very rare\*\* | \*\*Not known\*\* |
| \*\*System Organ Class\*\* |
| Blood and lymphatic system disorders | | | Agranulocytosis | Thrombocytopenia; Leucopenia, Pancytopennia | |
| Immune system disorders | | | Hypersenstivity (including anaphylactic reactions and anaphylactic shock) | | |
| Metabolism and nutrition disorders | | | Hyperlipidaemias and lipid increases (triglycerides, cholesterol); Weight changes | | Hyponatraemia; Hypomagnesaemia (\*see section 4.4)\* Hypocalcaemia1 Hypokalaemia1 |
| Psychiatric disorders | | Sleep disorders | Depression (and all aggravations) | Disorientation (and all aggravations) | Hallucination; Confusion (especially in pre-disposed patients, as well as the aggravation of these symptoms in case of pre-existence) |
| Nervous system disorders | | Headache; Dizziness | Taste disorders | | Paraesthesia |
| Eye disorders | | | Disturbances in vision / blurred vision | | |
| Gastrointestinal disorders | Fundic gland polyps (benign) | Diarrhoea; Nausea / vomiting; Abdominal distension and bloating; Constipation; Dry mouth; Abdominal pain and discomfort | | | Microscopic colitis |
| Hepatobiliary disorders | | Liver enzymes increased (transaminases, γ-GT) | Bilirubin increased | | Hepatocellular injury; Jaundice; Hepatocellular failure |
| Skin and sub-cutaneous tissue disorders | | Rash / exanthema / eruption; Pruritus | Urticaria; Angioedema | | Stevens-Johnson syndrome; Lyell syndrome; Erythema multiforme; Photosensitivity; Subacute cutaneous lupus erythematosus (see section 4.4); Drug reaction with eosinophilia and systemic symptoms (DRESS) |
| Musculoskeletal, connective tissue disorders | | Fracture of the hip, wrist or spine (\*see section 4.4\*) | Arthralgia; Myalgia | | Muscle spasm2 |
| Renal and urinary disorders | | | | | Tubulointerstitial nephritis (TIN) (with possible progression to renal failure) |
| Reproductive system and breast disorders | | | Gynaecomastia | | |
| General disorders and administration site conditions | | Asthenia, fatigue and malaise | Body temperature increased; Oedema peripheral | | |
1.Hypocalcaemia and/or hypokalaemia may be related to the occurrence of hypomagnesaemia (see section 4.4)
2 Muscle spasm as a consequence of electrolyte disturbance
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme, Website: https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
\*\*Symptoms\*\*
There are no known symptoms of overdose in man.
Systemic exposure with up to 240 mg administered intravenously over 2 minutes were well tolerated.
\*\*Management\*\*
As pantoprazole is extensively protein bound, it is not readily dialysable.
In the case of overdose with clinical signs of intoxication, apart from symptomatic and supportive treatment, no specific therapeutic recommendations can be made.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Proton pump inhibitors; ATC code: A02BC02
\*\*\*Mechanism of action\*\*\*
Pantoprazole is a substituted benzimidazole which inhibits the secretion of hydrochloric acid in the stomach by specific blockade of the proton pumps of the parietal cells.
Pantoprazole is converted to its active form in the acidic environment in the parietal cells where it inhibits the H+, K+-ATPase enzyme, i.e. the final stage in the production of hydrochloric acid in the stomach. The inhibition is dose-dependent and affects both basal and stimulated acid secretion. In most patients, freedom from symptoms is achieved within 2 weeks. As with other proton pump inhibitors and H2 receptor inhibitors, treatment with pantoprazole reduces acidity in the stomach and thereby increases gastrin in proportion to the reduction in acidity. The increase in gastrin is reversible. Since pantoprazole binds to the enzyme distal to the cell receptor level, it can inhibit hydrochloric acid secretion independently of stimulation by other substances (acetylcholine, histamine, gastrin). The effect is the same whether the product is given orally or intravenously.
\*\*Pharmacodynamic effects\*\*
The fasting gastrin values increase under pantoprazole. On short-term use, in most cases they do not exceed the upper limit of normal. During long-term treatment, gastrin levels double in most cases. An excessive increase, however, occurs only in isolated cases. As a result, a mild to moderate increase in the number of specific endocrine (ECL) cells in the stomach is observed in a minority of cases during long-term treatment (simple to adenomatoid hyperplasia). However, according to the studies conducted so far, the formation of carcinoid precursors (atypical hyperplasia) or gastric carcinoids as were found in animal experiments (see section 5.3) have not been observed in humans.
During treatment with antisecretory medicinal products, serum gastrin increases in response to the decreased acid secretion. Also CgA increases due to decreased gastric acidity. The increased CgA level may interfere with investigations for neuroendocrine tumours.
Available published evidence suggests that proton pump inhibitors should be discontinued between 5 days and 2 weeks prior to CgA measurements. This is to allow CgA levels that might be spuriously elevated following PPI treatment to return to reference range.
An influence of a long term treatment with pantoprazole exceeding one year cannot be completely ruled out on endocrine parameters of the thyroid according to results in animal studies.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Pantoprazole is rapidly absorbed and the maximal plasma concentration is achieved even after one single 40 mg oral dose. On average at about 2.5 h p.a. the maximum serum concentrations of about 2 - 3 μg/ml are achieved, and these values remain constant after multiple administration.
Pharmacokinetics do not vary after single or repeated administration. In the dose range of 10 to 80 mg, the plasma kinetics of pantoprazole are linear after both oral and intravenous administration.
The absolute bioavailability from the tablet was found to be about 77 %. Concomitant intake of food had no influence on AUC, maximum serum concentration and thus bioavailability. Only the variability of the lag-time will be increased by concomitant food intake.
\*\*Distribution\*\*
Pantoprazole's serum protein binding is about 98 %. Volume of distribution is about 0.15 l/kg.
\*\*Biotransformation\*\*
The substance is almost exclusively metabolized in the liver. The main metabolic pathway is demethylation by CYP2C19 with subsequent sulphate conjugation, other metabolic pathway include oxidation by CYP3A4.
\*\*Elimination\*\*
Terminal half-life is about 1 hour and clearance is about 0.1 l/h/kg. There were a few cases of subjects with delayed elimination. Because of the specific binding of pantoprazole to the proton pumps of the parietal cell the elimination half-life does not correlate with the much longer duration of action (inhibition of acid secretion).
Renal elimination represents the major route of excretion (about 80 %) for the metabolites of pantoprazole, the rest is excreted with the faeces. The main metabolite in both the serum and urine is desmethylpantoprazole which is conjugated with sulphate. The half-life of the main metabolite (about 1.5 hours) is not much longer than that of pantoprazole.
\*Special populations\*
\*\*Renal impairment\*\*
No dose reduction is recommended when pantoprazole is administered to patients with impaired renal function (including dialysis patients). As with healthy subjects, pantoprazole's half-life is short. Only very small amounts of pantoprazole are dialyzed. Although the main metabolite has a moderately delayed half-life (2 - 3 h), excretion is still rapid and thus accumulation does not occur.
\*\*Hepatic impairment\*\*
Although for patients with liver cirrhosis (classes A and B according to Child) the half-life values increased to between 7 and 9 h and the AUC values increased by a factor of 5 - 7, the maximum serum concentration only increased slightly by a factor of 1.5 compared with healthy subjects.
\*\*Elderly\*\*
A slight increase in AUC and Cmax in elderly volunteers compared with younger counterparts is also not clinically relevant.
\*\*Poor metabolisers\*\*
Approximately 3 % of the European population lack a functional CYP2C19 enzyme and are called poor metabolisers. In these individuals the metabolism of pantoprazole is probably mainly catalysed by CYP3A4. After a single-dose administration of 40 mg pantoprazole, the mean area under the plasma concentration-time curve was approximately 6 times higher in poor metabolisers than in subjects having a functional CYP2C19 enzyme (extensive metabolisers). Mean peak plasma concentrations were increased by about 60 %. These findings have no implications for the posology of pantoprazole.
\*\*Paediatric population\*\*
Following administration of single oral doses of 20 or 40 mg pantoprazole to children aged 5 - 16 years AUC and Cmax were in the range of corresponding values in adults.
Following administration of single i.v. doses of 0.8 or 1.6 mg/kg pantoprazole to children aged 2 - 16 years there was no significant association between pantoprazole clearance and age or weight. AUC and volume of distribution were in accordance with data from adults.5.3 Preclinical safety data
Preclinical data reveal no special hazard to humans based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity.
In the two-year carcinogenicity studies in rats neuroendocrine neoplasms were found. In addition, squamous cell papillomas were found in the forestomach of rats. The mechanism leading to the formation of gastric carcinoids by substituted benzimidazoles has been carefully investigated and allows the conclusion that it is a secondary reaction to the massively elevated serum gastrin levels occurring in the rat during chronic high-dose treatment. In the two-year rodent studies an increased number of liver tumors was observed in rats and in female mice and was interpreted as being due to pantoprazole's high metabolic rate in the liver.
A slight increase of neoplastic changes of the thyroid was observed in the group of rats receiving the highest dose (200 mg/kg). The occurrence of these neoplasms is associated with the pantoprazole-induced changes in the breakdown of thyroxine in the rat liver. As the therapeutic dose in man is low, no harmful effects on the thyroid glands are expected.
In a peri-postnatal rat reproduction study designed to assess bone development, signs of offspring toxicity (mortality, lower mean body weight, lower mean body weight gain and reduced bone growth) were observed at exposures (Cmax) approximately 2x the human clinical exposure. By the end of the recovery phase, bone parameters were similar across groups and body weights were also trending toward reversibility after a drug-free recovery period. The increased mortality has only been reported in pre-weaning rat pups (up to 21 days age) which is estimated to correspond to infants up to the age of 2 years old. The relevance of this finding to the paediatric population is unclear. A previous peri-postnatal study in rats at slightly lower doses found no adverse effects at 3 mg/kg compared with a low dose of 5 mg/kg in this study.
Investigations revealed no evidence of impaired fertility or teratogenic effects.
Penetration of the placenta was investigated in the rat and was found to increase with advanced gestation. As a result, concentration of pantoprazole in the foetus is increased shortly before birth.
## Pharmaceutical Particulars
6.1 List of excipients
\*\*Tablet\*\* \*\*\*core\*\*\*
Mannitol
Crospovidone (type A, type B)
Sodium carbonate
Sorbitol (E420)
Calcium stearate
\*\*Film\*\* \*\*\*coating\*\*\*
Hypromellose
Povidone (K25)
Titanium dioxide (E171)
Iron oxide, yellow (E172)
Propylene glycol
Methacrylic acid - ethyl acrylate copolymer
Sodium laurilsulfate
Polysorbate 80
Macrogol 6000
Talc6.2 Incompatibilities
Not applicable.6.3 Shelf life
5 years
\*\*\*HDPE container:\*\*\*
After first opening of the container, the product should be used within 3 months.6.4 Special precautions for storage
This medicinal product does not require any special temperature storage conditions.
Blister pack: Store in the original package in order to protect from moisture.
Container: Keep the container tightly closed in order to protect from moisture.6.5 Nature and contents of container
Blister pack (OPA/Aluminium/PVC film and aluminium foil) in a carton box.
Pack-sizes of 7, 14, 15, 20, 28, 30, 50, 50 x 1, 56, 60, 84, 90, 98, 100, 100 x 1, 112 and 140 gastro-resistant tablets.
HDPE containers with a silica gel desiccant in a tamper evident PP screw-cap.
Pack-size of 100 and 250 gastro-resistant tablets.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements.
