Proton pump inhibitors (PPIs) – pantoprazole sodium

Last updated on September 26, 2024

Generic name

pantoprazole sodium
Strength

40 mg

Form

tablet

Criteria

Approval period

1. For gastroesophageal reflux disease (GERD), reflux esophagitis, duodenal ulcer, or gastric ulcer

Indefinite

OR

 

2. For Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease, e.g., lupus, scleroderma, CREST

Indefinite

OR

 

3. For eradication of Helicobacter pylori as part of triple therapy

14 days

PLUS  

Failure of reasonable trials of, or intolerance to, rabeprazole AND pantoprazole magnesium
 
 

Practitioner exemptions

  • No practitioner exemptions

Special notes

  • CREST is an acronym for the five main features of the limited form of scleroderma: calcinosis, Raynaud’s disease, esophageal dysmotility, sclerodactyly, and telangiectasia.

  • A reasonable trial of rabeprazole and pantoprazole magnesium is considered a trial at usual adult doses for at least 4 weeks each of rabeprazole and pantoprazole magnesium.           

Special Authority requests