Pantoprazole interactions to avoid

Pantoprazole sodium, the generic version of Protonix, is a drug known as a proton pump inhibitor. Pantoprazole is approved by the Food and Drug Administration (FDA) to treat medical conditions such as gastroesophageal reflux disease (GERD), sometimes called acid reflux or heartburn. It can also help to lessen the effects of acid on the stomach and esophagus and to help prevent ulcers. Proton pump inhibitors were a significant addition to the treatment options for GERD. Proton pump inhibitors (PPIs) inhibit the gastric pumps responsible for stomach acid secretion. Pantoprazole is available in delayed-release oral tablets, oral suspension, and intravenous dosage forms. Early PPIs, such as Prilosec (omeprazole) and Prevacid (lansoprazole), interacted with the cytochrome P450 enzyme system. This enzyme system is responsible for the metabolism of many other drugs, so prescribers must be very careful with combining early PPIs with other medications. 

Pantoprazole, however, does not have a clinically significant effect on the cytochrome P450 system. Therefore, drug interactions related to pantoprazole have been shown to be much less of a concern than those of the earlier PPIs. However, this does not mean any concerns or serious side effects with pantoprazole and other medications. By nature of its mechanism of action, pantoprazole decreases the gastric pH (acid level), which can affect the absorption of other drugs dependent upon acid levels to break the drug down for absorption. It is important to be aware of how pantoprazole affects other drugs and also how other drugs and foods affect pantoprazole.

Key takeaways:

• Proton pump inhibitors should not be used with certain HIV antiretrovirals such as atazanavir, rilpivirine, or nelfinavir. Coadministration can affect the antiretrovirals’ blood levels, leading to higher viral loads and an increased risk of drug resistance. While this effect is thought to be less with pantoprazole than with older PPIs, most clinicians will still avoid this interaction whenever possible. 
• Pantoprazole can affect the blood in patients taking Coumadin (warfarin), Plavix (clopidogrel), or similar products. Prothrombin time and INR, markers for how likely the blood is to form clots, can increase, meaning the blood is less able to form clots. This can lead to abnormal bleeding and, in rare instances, death. 
• Some drugs depend upon gastric acid levels for their absorption and availability to the body. These include antifungals such as ketoconazole, itraconazole, and various iron salts. When the amount of acid levels are lower, these drugs aren’t broken down and, therefore, not as bioavailable to the body. In return, the body does not benefit from these drugs. 
• Long-term use of PPIs like pantoprazole can cause low magnesium levels. This is 

especially true if one is also on another drug that lowers magnesium, like diuretics. Low magnesium (hypomagnesemia) can lead to lower calcium (hypocalcemia) and potassium (hypokalemia) levels. This can increase the risk of joint pain, bone fractures, and osteoporosis.

• If taking a drug known or suspected to interact with pantoprazole, speak to a doctor or pharmacist immediately. The next action may depend on several factors, including the duration of anticipated pantoprazole therapy and how severe the interaction potential is.

Pantoprazole-drug interactions

Pantoprazole is contraindicated with certain HIV-indicated antiretroviral medications as absorption and efficacy of the HIV medication can be reduced, leading to drug resistance. Pantoprazole should be used cautiously in patients taking medication dependent upon an acidic gastric pH for absorption, such as certain antibiotics and iron products. Some products, like the over-the-counter supplement St. John’s Wort, can interfere with pantoprazole absorption, greatly decreasing the efficacy of pantoprazole. Below are some of the potential pantoprazole interactions to be aware of.

Antiretrovirals

Class: Protease inhibitors (PI)

• Reyataz (atazanavir)
• Viracept (nelfinavir)

Class: Non-nucleoside reverse transcriptase inhibitor (NNRTI)

• Edurant (rilpivirine)

Antiretrovirals are a class of drugs utilized for HIV treatment and prophylaxis. Certain antiretrovirals, including pantoprazole, are contraindicated and can not be used with proton pump inhibitors. These drugs depend on a very acidic environment in the gastrointestinal tract for optimal absorption. Viral load can increase without optimal absorption, and drug resistance can develop. There won’t necessarily be any symptoms related to this effect, but it will become evident in blood work over time. For this reason, all PPIs, including pantoprazole, are contraindicated with these specific antiretrovirals.

Patients needing acid reflux and heartburn relief while taking antiretrovirals have other options. Over-the-counter antacids (Tums, Maalox) and H2 inhibitors (Pepcid, Tagamet) can be taken while on antiretroviral therapy. Still, they must be spaced at least one hour before or two hours after the antiretroviral dose to minimize the negative absorption effect.

Antibiotics

• Principen (ampicillin)
• Unasyn (ampicillin/ sulbactam)
• Ceftin (cefuroxime)
• Vantin (cefpodoxime)

Some antibiotics are dependent upon a low gastric pH for optimal absorption. PPIs raise the gastric pH by decreasing the acid pumped into the stomach. Because of this, some particular antibiotics have greatly reduced bioavailability when given with PPIs like pantoprazole. This can lead to antibiotic resistance and a worsening of the bacterial infection. If taking an antibiotic as prescribed and the symptoms of infection are not improving, consult the prescriber immediately. Antibiotic resistance is a concern as bacteria continue to grow and mutate, rendering our current selection of antibiotics fragile when up against these mutated organisms.

If treatment with the PPI can not be discontinued, consider an alternative antibiotic treatment with less sensitivity to gastric pH where possible. If it is necessary to use a gastric pH-sensitive antibiotic, do not use PPIs concurrently, and consider OTC antacids or H2 blockers taken several hours apart from the antibiotic.

Antifungals

• Nizoral (ketoconazole)
• Recorlev (levoketoconazole)
• Sporanox (itraconazole)

Similar to select antiretrovirals and antibiotics, some antifungals require lower gastric pH for appropriate absorption. Without the lower pH, the antifungal drug has lower bioavailability and may not adequately treat the source of the fungal infection. Fungal infections can be very serious, especially once they enter the bloodstream. If being treated for a fungal infection and symptoms do not improve or worsen, seek medical care quickly. 

Neither H2 blockers or PPIs should be used with these antifungal drugs. Over-the-counter antacids under brand names like Tums or Rolaids can be given if spaced a few hours before or after administration of the antifungal. 

Cancer treatments- Kinase inhibitors

• Calquence (acalabrutinib)
• Bosulif (bosutinib)
• Sprycel (dasatinib)
• Tarceva (erlotinib)
• Nerlynx (neratinib)

Kinase inhibitors are a type of antineoplastic drug used to fight cancer. This group of drugs has successfully treated leukemias, lung cancer, and pancreatic cancer. Gastric pH plays a major role in the breakdown and absorption of these drugs. Without proper absorption, they can not help the battle against cancer to the fullest extent. 

For some, there may be ways around the interaction. For example, Calquence has a tablet and capsule formulation. The capsule formulation depends much more on a lower gastric pH for absorption than the tablet. The capsule absorption can be decreased by over 40% with a PPI. If a PPI is necessary while on Calquence, consider using the Calquence tablet. An H2 blocker like Tagamet or Pepcid is an acceptable alternative if spaced away from the kinase inhibitor by a few hours. 

Iron salts

• Fergon (iron salts)
• SlowFe (iron salts)
• Feosol (iron salts)
• Ferrex 150 (polysaccharide iron complex)

Iron depends on the stomach’s acidic environment to be reduced from ferric to ferrous forms that the body can absorb. Proton pump inhibitors like pantoprazole lower the gastric pH even after discontinuing them. This makes it difficult to absorb certain formulations of iron.

Methotrexate

• Trexall (methotrexate)

Methotrexate absorption can be increased when taken with pantoprazole. Using these drugs together is not recommended, especially at high doses, as methotrexate toxicities could occur.

Pantoprazole-food interactions

Pantoprazole and other proton pump inhibitors are best taken on an empty stomach. Data has shown that taking pantoprazole with food can delay and make absorption more variable. Pantoprazole should be taken on an empty stomach at least 30 minutes to one hour before eating each day for optimal absorption.

Certain foods can raise gastric pH and make one more prone to experiencing symptoms of acid reflux (GERD). To help keep the stomach acid level low, avoid foods like citrus fruits, tomatoes, chocolate, and spicy foods. 

Pantoprazole and grapefruit 

While pantoprazole is not affected by the cytochrome P450 effects of grapefruit the way many drugs are, grapefruit is still a citrus fruit, which naturally increases gastric acid and counteracts the effect of pantoprazole. Avoid foods and fruits like grapefruit to get the maximum benefit of pantoprazole. This applies to all PPIs, including Prilosec (omeprazole) and Nexium (esomeprazole).

Other pantoprazole interactions

Pantoprazole can interact with other common components of life, even if it is just a short-term treatment. This includes morning coffee and alcoholic beverages, even if just occasionally.

Pantoprazole and alcohol 

Alcohol inherently increases the acidic environment of the stomach. Even for occasional drinkers, this can cause adverse effects such as regurgitation and heartburn. Make sure to take pantoprazole on an empty stomach, but also know that if alcohol is ingested, there may be the need for a fast-acting acid reducer like Tums or Rolaids to help control symptoms if they spike. 

Pantoprazole and caffeine 

One may love to have a cup of coffee first thing in the morning, but this could be counteracting the efforts of the PPI, especially if consumed too soon. Pantoprazole should be taken first thing in the morning, ideally an hour before having anything else, including coffee. If eliminating coffee entirely isn’t feasible, adjusting the morning routine to have it later may be necessary.

RELATED: Can you drink coffee while taking Protonix?

Pantoprazole and marijuana

Marijuana, or THC as some medical experts will refer to it, is thought to increase the symptoms of GERD, though there are limited studies evaluating this relationship. Some say the effect on acid production is neutral. While THC is still considered an illegal substance in some states in the United States, it is thought to be used by at least 20% of the population, so understanding the link between it and the relationship to prescription drugs is increasingly important.

Another interesting link is that the use of pantoprazole has been linked to false positives on drug tests looking for the presence of THC. This is critical since many employers may require occasional drug tests for employment. If there are concerns about a false positive result due to pantoprazole use, work with the prescriber and pharmacist to understand the next steps.

How to minimize pantoprazole interactions

One of the most important aspects of taking pantoprazole is remembering to take it first thing in the morning before any other food, drinks, or medication. While pantoprazole does not have an extreme effect on enzymes responsible for the metabolism of other drugs, it greatly affects the gastric pH of the stomach and, therefore, the breakdown and absorption of drugs and foods that need acid for proper absorption. Taking it first thing in the morning will help reduce the common side effects and symptoms of acid reflux.

Do not take pantoprazole if there has ever been an allergic reaction to pantoprazole or another PPI. If there is a history of this reaction, inform the healthcare professional immediately. If a missed dose occurs and it is almost time for the next dose, skip the missed dose. Do not double up. Pantoprazole has been detected in the breast milk of mothers, and it is not recommended to take it when breastfeeding.

When to talk to a healthcare provider about pantoprazole interactions

If pantoprazole is not adequately controlling the symptoms of acid reflux or GERD, speak to a doctor or pharmacist. Make note of any recent changes in other medications or routines, as this could affect how well pantoprazole works. This article isn’t intended to be medical advice, and one should not stop taking medication without speaking to a healthcare provider.