Đề Xuất 11/2022 # Advocare Probiotics Restore Review, Ingredients And Side Effects / 2023 # Top 13 Like | Missvnuk.com

Đề Xuất 11/2022 # Advocare Probiotics Restore Review, Ingredients And Side Effects / 2023 # Top 13 Like

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Advocare Probiotics Restore is a health supplement designed to provide the ideal balance of probiotics for the human digestive system.

Good digestive health relies, in large part, on the balance of the good and bad bacteria living within the gut. Collectively, this mix of bacteria and yeast is referred to as the gut flora.

The healthy bacteria are considered to be probiotic because they confer a beneficial health effect on us when they are administered in adequate quantities.

Probiotic bacteria come in a wide variety of species and strains, each with their own unique potential health benefits.

Advocare Probiotics Restore contains seven different probiotic species in addition to a special type of stimulus (called a prebiotic) which is used to encourage them to replicate and colonize the small intestine and colon.

According to the manufacturer, this supplement can support the immune system, relieve symptoms of occasional constipation and help to maintain normal beneficial intestinal microflora.

Advocare also says that Probiotics Restore can enhance weight management and improve nutrient absorption from the diet.

Immune Function

Advocare Probiotics Restore Effects

Establishing a well-balanced probiotic colony in the intestines is important right from birth. Infants are born with a sterile digestive tract.

Their first plentiful source of probiotic bacteria usually is supplied via breast milk from their mothers. As they are exposed to sources of additional bacterial contaminants, their gastrointestinal tract begins to populate with bacterial species.

In a short period of time, a delicate balance is established among the microflora. Supplements like Advocare Probiotics Restore confer the same benefits as we age, helping to stimulate a healthier balance in the microflora.

Imbalances in the flora are thought to play a role in colic, bowel irregularity, lactose intolerance, various digestive disorders, constipation, and diarrhea. Studies show these imbalances may even play a part in how our immune system functions.

When the flora within the GI tract is in balance, it is more likely that digestive function is normal, bowel function is regular, nutrients are readily absorbed and the immune system functions optimally.

When should you Take Advocare Probiotics Restore?

In a healthy digestive system, when just one part of this delicately balanced system becomes disrupted, it can create an opening which allows pathogenic (unfriendly) bacteria to flourish and to potentially gain dominance. If this becomes excessive, health and wellness can be compromised.

One common example of disruption to the gut flora occurs when taking antibiotic medications.

Antibiotics work quickly to fight infection within our bodies but these powerful microbes also kill bacteria indiscriminately without taking notice of whether they are good or bad.

Many doctors recommend probiotics, like Advocare Probiotics Restore, to their patients immediately following a treatment with antibiotics.

Restoration of the gut flora can be accomplished through supplementation of these healthy harbingers much faster than when left on its own.

In addition to providing many of the most important strains of probiotics for overall health, Advocare Probiotics Restore includes fructooligosaccharides in their product. This is an insoluble natural fiber product known as a prebiotic.

Prebiotics stimulate microbiota within the large intestine, encouraging them to replicate and colonize. Prebiotics help make your probiotics work better and it is important to look for a supplement that includes both of these ingredients.

What to Expect

Many health conscious individuals choose to add Advocare Probiotics Restore to their daily regimen to help maintain a healthy balance in the natural gut ecosystem. This helps with the absorption of essential nutrients by improving permeability of the intestinal walls (the lumen).

Furthermore, it may be able to make weight easier to manage via better digestive health, work to enhance proper immune function and often increase bowel regularity, offering relief from constipation or diarrhea.

When the gut flora is in balance, symptoms associated with auto-immune related disorders like IBS (Irritable Bowel Syndrome) and Crohn’s Disease are reported to ease.

Specific strains of probiotic bacteria are thought to work together symbiotically to provide relief from bloating, abdominal discomfort and gas.

The average Western diet consists of foods which are high in fat but low in fiber – a combination which sets the gut microflora up for pathogenic bacterial domination.

A complete change in diet may not be possible, but supplementation with Advocare Probiotics Restore may help to offset diet-based imbalances which may be occurring.

Sources and Dosage

The manufacturer suggests one capsule be taken 30 minutes before a meal, 1-2 times each day.

Some individuals report better results when taking two capsules before meals, especially in the early stages of supplementation.

Each capsule contains a minimum of 6 billion viable cultures at the time of manufacture. This is at the lower end of the spectrum for probiotic supplements as many of the highest quality products will contain 30 billion CFUs per dosage.

It is unknown how many live cultures survive until the time of ingestion. Storing at temperatures below 80 degrees Fahrenheit will assure best viability.

Side Effects

Probiotics are usually tolerated well by a majority of people. Side effects, if any, are usually quite mild and generally will subside with continued use.

Pregnant or nursing mothers should consult their physician before taking Advocare Probiotics Restore, or any product containing prebiotics.

Individuals whose immune system is known to be compromised, such as those taking immunosuppressive medications, should not take probiotics.

Review

Probiotic supplementation is a safe and effective means of supporting intestinal health and function by providing additional healthy bacteria to offset imbalances in the gut microflora.

At any given time, the average adult has over three pounds of these bacteria within their system, all fighting for dominance and space in which to colonize.

Daily supplementation with Advocare Probiotics Restore or Advocare Probiotics Restore Ultra may contribute to a better balance of the flora throughout the GI tract, resulting in better bowel, digestive and immune function.

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Patel RM, Denning PW. Therapeutic use of prebiotics, probiotics, and postbiotics to prevent necrotizing enterocolitis: what is the current evidence? Clin Perinatol. 2013

Patel A, Shah N, Prajapati JB. Clinical application of probiotics in the treatment of Helicobacter pylori infection–a brief review. J Microbiol Immunol Infect. 2014

Barraud D, Bollaert PE, Gibot S. Impact of the administration of probiotics on mortality in critically ill adult patients: a meta-analysis of randomized controlled trials. Chest. 2013

Barrett HL, Dekker Nitert M, Conwell LS, Callaway LK. Probiotics for preventing gestational diabetes. Cochrane Database Syst Rev. 2014

Pradeep K, Kuttappa MA, Prasana KR. Probiotics and oral health: an update. SADJ. 2014

Kirk J, Dunker KS. Dietary counseling: the ingredient for successfully addressing the use of herbal supplements and probiotics in chronic kidney disease. Adv Chronic Kidney Dis. 2014

Müllner K, Miheller P, Herszényi L, Tulassay Z. Probiotics in the management of Crohn’s disease and ulcerative colitis. Curr Pharm Des. 2014

Didari T, Solki S, Mozaffari S, Nikfar S, Abdollahi M. A systematic review of the safety of probiotics. Expert Opin Drug Saf. 2014

Article last updated on: May 2nd, 2018 by Nootriment

Biogaia Probiotics Drops Review, Side Effects + Buy Online / 2023

BioGaia Probiotics Drops is a specially formulated supplement designed for infants experiencing symptoms which are typically identified as colic or other recurring digestive system upset.

Probiotic supplements for infants are easily dispensed through the use of liquid drops which can be added to formula, juice or breast milk.

According to the manufacturer, “BioGaia contains L. reuteri Protectis, a health-giving probiotic that naturally colonizes the digestive tract and is even found in the milk of breastfeeding mothers. By strengthening and reinforcing the good bacteria in a baby’s digestive tract, BioGaia promotes digestive comfort.”

BioGaia Probiotics drops work to balance the infant gut flora, allowing for a natural ratio of good (healthy) to bad (unhealthy) bacteria.

The use of probiotics in babies has been shown to reduce crying time and to ease other common infant digestive issues, like gas, which contribute to general discomfort and infant fussiness.

BioGaia Probiotics Drops also contains 400 IUs of vitamin D3, which plays a role in bone health. Most children do not get enough of this vitamin from their diet.

Immune Function

How Biogaia Probiotics Drops Work

Probiotic bacteria are those microorganisms which, when administered in adequate amounts, confer a positive benefit to their host.

Biogaia Probiotics Drops are produced with sufficient quantities of a patented probiotic strain designed to help babies and young children who are experiencing digestive discomfort.

Eventually, the research director of Biogaia was able to locate and isolate a strain of the bacteria from the breast milk of women who live in the Peruvian Andes.

This strain is still used in BioGaia’s probiotic products all over the world.

Benefits

The effects of probiotics can vary from person to person, but, in general, each species and strain appears to have uniquely different benefits. The effects of L. reuteri (the species of probiotic used in BioGaia’s infant drops) are well supported through double-blind, placebo-controlled studies.

In particular, Lactobacillus reuteri protectis has been shown to ease symptoms associated with colic, constipation and regurgitation in infants. Other studies suggest the spread of contagious diarrhea in day-care settings can be reduced through the administration of this friendly bacterium.

Colic: Recent research demonstrates a reduction in symptoms associated with colic in babies. A study published in the JAMA Pediatrics online publication in January of 2014 enlisted over 450 infants.

During the course of the study, half of the newborn infants received placebo drops while the other half received drops containing Lactobacillus reuteri protectis once daily for a period of 90 days.

After only 30 days, the group of babies receiving the probiotic drops cried less than half as long each day when compared to the babies receiving the placebo.

After 90 days, crying time of the infants receiving probiotic drops remained significant in comparison to the placebo group, with over 40% reduction in crying time.

Researchers also noted that the probiotics group had 30% more bowel movements each day and less regurgitation, suggesting better gut motility due to change in the gut microflora balance.

Over 300 children ranging in age from 6-months to 3-years of age were divided evenly into placebo and non-placebo groups. They were given Lactobacillus reuteri protectis probiotic drops for a 12-week period, followed by a 12-week period without any drops.

The group receiving the probiotic drops experienced less than half the episodes and duration of diarrhea as their counterparts receiving the placebo. An almost identical outcome was reported with regards to respiratory illness.

Dosage and Side Effects

Biogaia Probiotics Drops are administered once daily in 5-drop doses. Each dose contains 100 million CFU (colony forming units) of L. reuteri protectis probiotic bacteria.

If ordering directly from the manufacturer, this product may arrive in a temperature controlled container, but the drops do not need to be kept refrigerated.

Instead, the manufacturer states they must be kept in an environment below 77 degrees Fahrenheit for the bacteria to remain viable. In many households, this makes the drops a shelf-stable supplement.

The manufacturer ships in temperature controlled packaging to protect the fragile bacteria from unstable and undetermined temperatures during the shipping process.

This product has been shown to be safe for a majority of infants though it is always recommended to check with your pediatrician before starting your infant on any new health regimen.

Biogaia Probiotic Drops Review

Probiotics are considered generally safe for both babies and children.

You can buy Biogaia Probiotic Drops online or from specialty health stores in your local area.

Baquerizo Nole KL, Yim E, Keri JE. Probiotics and prebiotics in dermatology. J Am Acad Dermatol. 2014

Gu WJ, Deng T, Gong YZ, Jing R, Liu JC. The effects of probiotics in early enteral nutrition on the outcomes of trauma: a meta-analysis of randomized controlled trials. JPEN J Parenter Enteral Nutr. 2013

Guinane S. The effectiveness of probiotics for managing diarrhoea in people with HIV infection: a critically appraised topic. HIV Med. 2013

Urben LM, Wiedmar J, Boettcher E, Cavallazzi R, Martindale RG, McClave SA. Bugs or drugs: are probiotics safe for use in the critically ill? Curr Gastroenterol Rep. 2014

Szajewska H. Understanding the role of probiotics and prebiotics in preventing allergic disease: evidence and methodological issues. Immunotherapy. 2013

AlFaleh K, Anabrees J. Efficacy and safety of probiotics in preterm infants. J Neonatal Perinatal Med. 2013

Borges S, Silva J, Teixeira P. The role of lactobacilli and probiotics in maintaining vaginal health. Arch Gynecol Obstet. 2014

Bellavia M, Tomasello G, Romeo M, Damiani P, Lo Monte AI, Lozio L, Campanella C, Marino Gammazza A, Rappa F, Zummo G, Cocchi M, Conway de Macario E, Macario AJ, Cappello F. Gut microbiota imbalance and chaperoning system malfunction are central to ulcerative colitis pathogenesis and can be counteracted with specifically designed probiotics: a working hypothesis. Med Microbiol Immunol. 2013

Article last updated on: May 3rd, 2018 by Nootriment

Protonix (Pantoprazole): Uses, Dosage, Side Effects, Interactions, Warning / 2023

What is Protonix and how is it used?

Protonix is a prescription medicine used to treat the symptoms of esophagitis caused by stomach acid due to gastroesophageal reflux disease or GERD and Zollinger-Ellison syndrome or other conditions causing excess stomach acid. Protonix may be used alone or with other medications.

Protonix belongs to a class of drugs called proton pump inhibitors (PPIs).

It is not known if Protonix is safe and effective in children younger than 5 years of age.

What are the possible side effects of Protonix?

Protonix may cause serious side effects, including:

severe stomach pain,

diarrhea that is watery or has blood in it,

sudden pain or difficulty moving your hip, wrist or back,

bruising or swelling at the injection site,

little or no urination,

blood in the urine,

swelling,

rapid weight gain,

dizziness,

fast or irregular heartrate,

tremors (shaking) or jerky movements,

feeling jittery,

muscle cramps or spasms in your hands or feet,

cough,

choking feeling,

joint pain, and

skin rash on your cheeks or arms which worsens at night

Get medical help right away, if you have any of the symptoms listed above.

The most common side effects of Protonix include:

headache,

dizziness,

stomach pain,

gas,

nausea,

vomiting,

diarrhea,

joint pain,

fever,

rash, and

cold symptoms (most common in children)

Tell your doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of Prometrium. For more information, ask your doctor or pharmacist.

DESCRIPTION

The active ingredient in PROTONIX (pantoprazole sodium) For Delayed-Release Oral Suspension and PROTONIX (pantoprazole sodium) Delayed-Release Tablets, a PPI, is a substituted benzimidazole, sodium 5-(difluoromethoxy)-2-[[(3,4-dimethoxy-2- pyridinyl)methyl] sulfinyl]-1 H-benzimidazole sesquihydrate, a compound that inhibits gastric acid secretion. Its empirical formula is C 16H 14F 2N 3NaO 4S x 1.5 H 2 O, with a molecular weight of 432.4. The structural formula is:

Pantoprazole sodium sesquihydrate is a white to off-white crystalline powder and is racemic. Pantoprazole has weakly basic and acidic properties. Pantoprazole sodium sesquihydrate is freely soluble in water, very slightly soluble in phosphate buffer at pH 7.4, and practically insoluble in n-hexane.

The stability of the compound in aqueous solution is pH-dependent. The rate of degradation increases with decreasing pH. At ambient temperature, the degradation half-life is approximately 2.8 hours at pH 5 and approximately 220 hours at pH 7.8.

PROTONIX is supplied as a for delayed-release oral suspension in unit dose packets, available in one strength (40 mg) pantoprazole, (equivalent to 45.1 mg of pantoprazole sodium), and as a delayed-release tablet, available in two strengths 20 mg pantoprazole (equivalent to 22.56 mg of pantoprazole sodium) and 40 mg pantoprazole (equivalent to 45.1 mg of pantoprazole sodium).

PROTONIX Delayed-Release Tablets contain the following inactive ingredients: calcium stearate, crospovidone, hypromellose, iron oxide, mannitol, methacrylic acid copolymer, polysorbate 80, povidone, propylene glycol, sodium carbonate, sodium lauryl sulfate, titanium dioxide, and triethyl citrate. PROTONIX Delayed-Release Tablets (40 mg and 20 mg) complies with USP dissolution test 2.

PROTONIX For Delayed-Release Oral Suspension contains the following inactive ingredients: crospovidone, hypromellose, methacrylic acid copolymer, microcrystalline cellulose, polysorbate 80, povidone, sodium carbonate, sodium lauryl sulfate, talc, titanium dioxide, triethyl citrate, and yellow ferric oxide.

3 pharmacies near 20147 have coupons for Protonix (Brand Names:Protonix for 20MG)

INDICATIONS

PROTONIX For Delayed-Release Oral Suspension and PROTONIX Delayed-Release Tablets are indicated for:

Short-Term Treatment Of Erosive Esophagitis Associated With Gastroesophageal Reflux Disease (GERD)

PROTONIX is indicated in adults and pediatric patients five years of age and older for the short-term treatment (up to 8 weeks) in the healing and symptomatic relief of erosive esophagitis (EE). For those adult patients who have not healed after 8 weeks of treatment, an additional 8-week course of PROTONIX may be considered. Safety of treatment beyond 8 weeks in pediatric patients has not been established.

Maintenance Of Healing Of Erosive Esophagitis

PROTONIX is indicated for maintenance of healing of EE and reduction in relapse rates of daytime and nighttime heartburn symptoms in adult patients with GERD. Controlled studies did not extend beyond 12 months.

Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome

PROTONIX is indicated for the long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison (ZE) Syndrome.

SLIDESHOW

See Slideshow

DOSAGE AND ADMINISTRATION

Recommended Dosing Schedule

PROTONIX is supplied as delayed-release granules in packets for preparation of oral suspensions or as delayed-release tablets. The recommended dosages are outlined in Table 1.

Table 1: Recommended Dosing Schedule for PROTONIX

Short-Term Treatment of Erosive Esophagitis Associated With GERD

Children (5 years and older)

Maintenance of Healing of Erosive Esophagitis Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome

* For adult patients who have not healed after 8 weeks of treatment, an additional 8-week course of PROTONIX may be considered.** Dosage regimens should be adjusted to individual patient needs and should continue for as long as clinically indicated. Doses up to 240 mg daily have been administered.*** Controlled studies did not extend beyond 12 months

Administration Instructions

Directions for method of administration for each dosage form are presented in Table 2.

Table 2: Administration Instructions

Take a missed dose as soon as possible. If it is almost time for the next dose, skip the missed dose and take the next dose at the regular scheduled time. Do not take 2 doses at the same time.

PROTONIX Delayed-Release Tablets

Swallow PROTONIX Delayed-Release Tablets whole, with or without food in the stomach. For patients unable to swallow a 40 mg tablet, two 20 mg tablets may be taken. Concomitant administration of antacids does not affect the absorption of PROTONIX Delayed-Release Tablets.

PROTONIX For Delayed-Release Oral Suspension

Administer PROTONIX For Delayed-Release Oral Suspension approximately 30 minutes prior to a meal via oral administration in apple juice or applesauce or nasogastric tube in apple juice only. Because proper pH is necessary for stability, do not administer PROTONIX For Delayed-Release Oral Suspension in liquids other than apple juice, or foods other than applesauce.

Do not divide the 40 mg PROTONIX For Delayed-Release Oral Suspension packet to create a 20 mg dosage for pediatric patients who are unable to take the tablet formulation.

PROTONIX For Delayed-Release Oral Suspension -Oral Administration In Applesauce

Open packet.

Sprinkle granules on one teaspoonful of applesauce. DO NOT USE OTHER FOODS OR CRUSH OR CHEW THE GRANULES.

Take within 10 minutes of preparation.

Take sips of water to make sure granules are washed down into the stomach. Repeat water sips as necessary.

PROTONIX For Delayed-Release Oral Suspension -Oral Administration In Apple Juice

Open packet.

Empty granules into a small cup or teaspoon containing one teaspoon of apple juice.

Stir for 5 seconds (granules will not dissolve) and swallow immediately.

To make sure that the entire dose is taken, rinse the container once or twice with apple juice to remove any remaining granules. Swallow immediately.

PROTONIX For Delayed-Release Oral Suspension -Nasogastric (NG) Tube Or Gastrostomy Tube Administration

For patients who have a nasogastric tube or gastrostomy tube in place, PROTONIX For Delayed-Release Oral Suspension can be given as follows:

Remove the plunger from the barrel of a 2 ounce (60 mL) catheter-tip syringe. Discard the plunger.

Connect the catheter tip of the syringe to a 16 French (or larger) tube.

Hold the syringe attached to the tubing as high as possible while giving PROTONIX For Delayed-Release Oral Suspension to prevent any bending of the tubing.

Empty the contents of the packet into the barrel of the syringe.

Add 10 mL (2 teaspoonfuls) of apple juice and gently tap and/or shake the barrel of the syringe to help rinse the syringe and tube. Repeat at least twice more using the same amount of apple juice (10 mL or 2 teaspoonfuls) each time. No granules should remain in the syringe.

HOW SUPPLIED

Dosage Forms And Strengths

Delayed-Release Tablets:

40 mg pantoprazole, yellow oval biconvex tablets imprinted with PROTONIX (brown ink) on one side

20 mg pantoprazole, yellow oval biconvex tablets imprinted with P20 (brown ink) on one side

For Delayed-Release Oral Suspension:

40 mg pantoprazole, pale yellowish to dark brownish, enteric-coated granules in a unit dose packet

Storage And Handling

PROTONIX (pantoprazole sodium) Delayed-Release Tablets are supplied as yellow, oval biconvex delayed-release tablets imprinted with PROTONIX (brown ink) on one side containing 40 mg pantoprazole and are available as follows:

NDC 0008-0841-81, bottles of 90

PROTONIX (pantoprazole sodium) Delayed-Release Tablets are supplied as yellow oval biconvex delayed-release tablets imprinted with P20 (brown ink) on one side containing 20 mg pantoprazole and are available as follows:

NDC 0008-0843-81, bottles of 90

PROTONIX (pantoprazole sodium) For Delayed-Release Oral Suspension is supplied as pale yellowish to dark brownish, enteric-coated granules containing 40 mg pantoprazole in a unit-dose packet and are available as follows:

NDC 0008-0844-02, unit-dose carton of 30

Storage

Store PROTONIX For Delayed-Release Oral Suspension and PROTONIX Delayed-Release Tablets at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature].

Distributed by: Wyeth Pharmaceuticals LLC, A subsidiary of Pfizer Inc., Philadelphia, PA 19101. Revised: Nov 2020

SIDE EFFECTS

Acute Tubulointerstitial Nephritis [see WARNINGS AND PRECAUTIONS]

Clostridium difficile-Associated Diarrhea [see WARNINGS AND PRECAUTIONS]

Bone Fracture [see WARNINGS AND PRECAUTIONS]

Cutaneous and Systemic Lupus Erythematosus [see WARNINGS AND PRECAUTIONS]

Cyanocobalamin (Vitamin B-12) Deficiency [see WARNINGS AND PRECAUTIONS]

Hypomagnesemia [see WARNINGS AND PRECAUTIONS]

Fundic Gland Polyps [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

Adults

PROTONIX(n=1473) %

Comparators(n=345) %

Placebo(n=82) %

Body as a Whole: allergic reaction, pyrexia, photosensitivity reaction, facial edema

Gastrointestinal: constipation, dry mouth, hepatitis

Hematologic: leukopenia, thrombocytopenia

Metabolic/Nutritional: elevated CK (creatine kinase), generalized edema, elevated triglycerides, liver enzymes elevated

Musculoskeletal: myalgia

Nervous: depression, vertigo

Skin and Appendages: urticaria, rash, pruritus

Special Senses: blurred vision

Pediatric Patients

For safety information in patients less than 1 year of age see Use In Specific Populations.

Body as a Whole: allergic reaction, facial edema

Gastrointestinal: constipation, flatulence, nausea

Metabolic/Nutritional: elevated triglycerides, elevated liver enzymes, elevated CK (creatine kinase)

Musculoskeletal: arthralgia, myalgia

Nervous: dizziness, vertigo

Skin and Appendages: urticaria

Zollinger-Ellison (ZE) Syndrome

Postmarketing Experience

Gastrointestinal Disorders: fundic gland polyps

General Disorders and Administration Conditions: asthenia, fatigue, malaise

Hematologic: pancytopenia, agranulocytosis

Hepatobiliary Disorders: hepatocellular damage leading to jaundice and hepatic failure

Immune System Disorders: anaphylaxis (including anaphylactic shock), systemic lupus erythematosus

Infections and Infestations: Clostridium difficile associated diarrhea

Investigations: weight changes

Metabolism and Nutritional Disorders: hyponatremia, hypomagnesemia

Musculoskeletal Disorders: rhabdomyolysis, bone fracture

Nervous: ageusia, dysgeusia

Psychiatric Disorders: hallucination, confusion, insomnia, somnolence

Renal and Urinary Disorders: acute tubulointerstitial nephritis

Skin and Subcutaneous Tissue Disorders: severe dermatologic reactions (some fatal), including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN, some fatal), angioedema (Quincke’s edema) and cutaneous lupus erythematosus

DRUG INTERACTIONS

Table 4 includes drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with PROTONIX and instructions for preventing or managing them.

Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs.

Table 4: Clinically Relevant Interactions Affecting Drugs Co-Administered with PROTONIX and Interactions with Diagnostics

Antiretrovirals Clinical Impact:

The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.

Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with pantoprazole may reduce antiviral effect and promote the development of drug resistance.

Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with pantoprazole may increase toxicity of the antiretroviral drugs.

There are other antiretroviral drugs which do not result in clinically relevant interactions with pantoprazole.

Intervention:

Rilpivirine-containing products: Concomitant use with PROTONIX is contraindicated [see CONTRAINDICATIONS]. See prescribing information.Atazanavir: See prescribing information for atazanavir for dosing information.Nelfinavir: Avoid concomitant use with PROTONIX. See prescribing information for nelfinavir.Saquinavir: See the prescribing information for saquinavir and monitor for potential saquinavir toxicities.Other antiretrovirals: See prescribing information.

Warfarin Clopidogrel Clinical Impact:

Concomitant administration of pantoprazole and clopidogrel in healthy subjects had no clinically important effect on exposure to the active metabolite of clopidogrel or clopidogrel-induced platelet inhibition [see CLINICAL PHARMACOLOGY].

Methotrexate Clinical Impact:

Concomitant use of PPIs with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted [see WARNINGS AND PRECAUTIONS].

Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole) Intervention:

Mycophenolate mofetil (MMF): Co-administration of pantoprazole sodium in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH [see CLINICAL PHARMACOLOGY]. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving PROTONIX and MMF. Use PROTONIX with caution in transplant patients receiving MMF.See the prescribing information for other drugs dependent on gastric pH for absorption.

Interactions with Investigations of Neuroendocrine Tumors Clinical Impact:

CgA levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors [see WARNINGS AND PRECAUTIONS, CLINICAL PHARMACOLOGY].

False Positive Urine Tests for THC Clinical Impact:

There have been reports of false positive urine screening tests for tetrahydrocannabinol (THC) in patients receiving PPIs [see WARNINGS AND PRECAUTIONS].

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Presence Of Gastric Malignancy

In adults, symptomatic response to therapy with PROTONIX does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.

Acute Tubulointerstitial Nephritis

Acute tubulointerstitial nephritis (TIN) has been observed in patients taking PPIs and may occur at any point during PPI therapy. Patients may present with varying signs and symptoms from symptomatic hypersensitivity reactions to non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). In reported case series, some patients were diagnosed on biopsy and in the absence of extra-renal manifestations (e.g., fever, rash or arthralgia). Discontinue PROTONIX and evaluate patients with suspected acute TIN [see CONTRAINDICATIONS].

Clostridium difficile-Associated Diarrhea

Published observational studies suggest that PPI therapy like PROTONIX may be associated with an increased risk of Clostridium difficile associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve [see ADVERSE REACTIONS].

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Bone Fracture

Several published observational studies suggest that PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS].

Cutaneous And Systemic Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus ( SLE) have been reported in patients taking PPIs, including pantoprazole sodium. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematous cases were CLE.

The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement.

Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving PROTONIX, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g. ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.

Cyanocobalamin (Vitamin B-12) Deficiency

Generally, daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than 3 years) may lead to malabsorption of cyanocobalamin (Vitamin B-12) caused by hypo-or achlorhydria. Rare reports of cyanocobalamin deficiency occurring with acid-suppressing therapy have been reported in the literature. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed.

Hypomagnesemia

For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see ADVERSE REACTIONS].

Tumorigenicity

Due to the chronic nature of GERD, there may be a potential for prolonged administration of PROTONIX. In long-term rodent studies, pantoprazole was carcinogenic and caused rare types of gastrointestinal tumors. The relevance of these findings to tumor development in humans is unknown [see Nonclinical Toxicology].

Fundic Gland Polyps

PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated.

Interference With Investigations For Neuroendocrine Tumors

Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop PROTONIX treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary [see CLINICAL PHARMACOLOGY].

Interference With Urine Screen For THC

There have been reports of false-positive urine screening tests for tetrahydrocannabinol (THC) in patients receiving PPIs, including PROTONIX [see DRUG INTERACTIONS].

Concomitant Use Of PROTONIX With Methotrexate

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of the PPI may be considered in some patients [see DRUG INTERACTIONS].

Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling ( Medication Guide and Instructions for Use).

Gastric Malignancy

Advise patients to return to their healthcare provider if they have a suboptimal response or an early symptomatic relapse [see WARNINGS AND PRECAUTIONS].

Acute Tubulointerstitial Nephritis

Advise patients to call their healthcare provider immediately if they experience signs and/or symptoms associated with acute tubulointerstitial nephritis [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].

Clostridium Difficile-Associated Diarrhea

Advise patients to immediately call their healthcare provider if they experience diarrhea that does not improve [see WARNINGS AND PRECAUTIONS].

Bone Fracture

Advise patients to report any fractures, especially of the hip, wrist or spine, to their healthcare provider [see WARNINGS AND PRECAUTIONS].

Cutaneous And Systemic Lupus Erythematosus

Advise patients to immediately call their healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see WARNINGS AND PRECAUTIONS].

Cyanocobalamin (Vitamin B-12) Deficiency

Advise patients to report any clinical symptoms that may be associated with cyancobalamin deficiency to their healthcare provider if they have been receiving PROTONIX for longer than 3 years [see WARNINGS AND PRECAUTIONS].

Hypomagnesemia

Advise patients to report any clinical symptoms that may be associated with hypomagnesemia to their healthcare provider, if they have been receiving PROTONIX for at least 3 months [see WARNINGS AND PRECAUTIONS].

Drug Interactions

Instruct patients to inform their healthcare provider of any other medications they are currently taking, including rilpivirine-containing products [see CONTRAINDICATIONS] digoxin [see WARNINGS AND PRECAUTIONS] and high dose methotrexate [see WARNINGS AND PRECAUTIONS].

Pregnancy

Advise a pregnant woman of the potential risk to a fetus. Advise females of reproductive potential to inform their healthcare provider of a known or suspected pregnancy [see Use In Specific Populations].

Administration

Do not split, crush, or chew PROTONIX For Delayed-Release Oral Suspension and PROTONIX Delayed-Release Tablets.

PROTONIX oral suspension packet is a fixed dose and cannot be divided to make a smaller dose.

Swallow PROTONIX Delayed-Release Tablets whole, with or without food in the stomach.

Concomitant administration of antacids does not affect the absorption of PROTONIX Delayed-Release Tablets.

Take PROTONIX For Delayed-Release Oral Suspension approximately 30 minutes before a meal.

Administer PROTONIX For Delayed-Release Oral Suspension in apple juice or applesauce, as described in the Instructions for Use. Do not administer in water, other liquids, or foods.

For patients with a nasogastric (NG) or gastrostomy tube, PROTONIX For Delayed-Release Oral Suspension can be administered with apple juice, as described in the Instructions for Use.

Take a missed dose as soon as possible. If it is almost time for the next dose, skip the missed dose and take the next dose at the regular scheduled time. Do not take 2 doses at the same time.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

In a 24-month carcinogenicity study, Sprague-Dawley rats were treated orally with pantoprazole doses of 0.5 to 200 mg/kg/day, about 0.1 to 40 times the exposure on a body surface area basis of a 50 kg person dosed with 40 mg/day. In the gastric fundus, treatment with 0.5 to 200 mg/kg/day produced enterochromaffin-like (ECL) cell hyperplasia and benign and malignant neuroendocrine cell tumors in a dose-related manner. In the forestomach, treatment with 50 and 200 mg/kg/day (about 10 and 40 times the recommended human dose on a body surface area basis) produced benign squamous cell papillomas and malignant squamous cell carcinomas. Rare gastrointestinal tumors associated with pantoprazole treatment included an adenocarcinoma of the duodenum with 50 mg/kg/day and benign polyps and adenocarcinomas of the gastric fundus with 200 mg/kg/day. In the liver, treatment with 0.5 to 200 mg/kg/day produced dose-related increases in the incidences of hepatocellular adenomas and carcinomas. In the thyroid gland, treatment with 200 mg/kg/day produced increased incidences of follicular cell adenomas and carcinomas for both male and female rats.

In a 24-month carcinogenicity study, Fischer 344 rats were treated orally with doses of 5 to 50 mg/kg/day of pantoprazole, approximately 1 to 10 times the recommended human dose based on body surface area. In the gastric fundus, treatment with 5 to 50 mg/kg/day produced enterochromaffin-like (ECL) cell hyperplasia and benign and malignant neuroendocrine cell tumors. Dose selection for this study may not have been adequate to comprehensively evaluate the carcinogenic potential of pantoprazole.

In a 24-month carcinogenicity study, B6C3F1 mice were treated orally with doses of 5 to 150 mg/kg/day of pantoprazole, 0.5 to 15 times the recommended human dose based on body surface area. In the liver, treatment with 150 mg/kg/day produced increased incidences of hepatocellular adenomas and carcinomas in female mice. Treatment with 5 to 150 mg/kg/day also produced gastric-fundic ECL cell hyperplasia.

A 26-week p53 +/- transgenic mouse carcinogenicity study was not positive.

Pantoprazole was positive in the in vitro human lymphocyte chromosomal aberration assays, in one of two mouse micronucleus tests for clastogenic effects, and in the in vitro Chinese hamster ovarian cell/HGPRT forward mutation assay for mutagenic effects. Equivocal results were observed in the in vivo rat liver DNA covalent binding assay. Pantoprazole was negative in the in vitro Ames mutation assay, the in vitro unscheduled DNA synthesis (UDS) assay with rat hepatocytes, the in vitro AS52/GPT mammalian cell-forward gene mutation assay, the in vitro thymidine kinase mutation test with mouse lymphoma L5178Y cells, and the in vivo rat bone marrow cell chromosomal aberration assay.

There were no effects on fertility or reproductive performance when pantoprazole was given at oral doses up to 500 mg/kg/day in male rats (98 times the recommended human dose based on body surface area) and 450 mg/kg/day in female rats (88 times the recommended human dose based on body surface area).

Use In Specific Populations

Pregnancy

Risk Summary

A pre-and postnatal development toxicity study in rats with additional endpoints to evaluate the effect on bone development was performed with pantoprazole sodium. Oral pantoprazole doses of 5, 15, and 30 mg/kg/day (approximately 1, 3, and 6 times the human dose of 40 mg/day) were administered to pregnant females from gestation day ( GD) 6 through lactation day (LD) 21. Changes in bone morphology were observed in pups exposed to pantoprazole in utero and through milk during the period of lactation as well as by oral dosing from postnatal day (PND) 4 through PND 21 [see Use In Specific Populations]. There were no drug-related findings in maternal animals. Advise pregnant women of the potential risk of fetal harm.

Data

Animal Data

Reproduction studies have been performed in rats at oral pantoprazole doses up to 450 mg/kg/day (about 88 times the recommended human dose based on body surface area) and in rabbits at oral doses up to 40 mg/kg/day (about 16 times the recommended human dose based on body surface area) with administration of pantoprazole sodium during organogenesis in pregnant animals. The studies have revealed no evidence of impaired fertility or harm to the fetus due to pantoprazole.

A pre-and postnatal development toxicity study in rats with additional endpoints to evaluate the effect on bone development was performed with pantoprazole sodium. Oral pantoprazole doses of 5, 15, and 30 mg/kg/day (approximately 1, 3, and 6 times the human dose of 40 mg/day on a body surface area basis) were administered to pregnant females from gestation day (GD) 6 through lactation day (LD) 21. On postnatal day (PND 4) through PND 21, the pups were administered oral doses at 5, 15, and 30 mg/kg/day (approximately 1, 2.3, and 3.2 times the exposure (AUC) in humans at a dose of 40 mg). There were no drug-related findings in maternal animals. During the preweaning dosing phase (PND 4 to 21) of the pups, there were increased mortality and/or moribundity and decreased body weight and body weight gain at 5 mg/kg/day (approximately equal exposures (AUC) in humans receiving the 40 mg dose) and higher doses. On PND 21, decreased mean femur length and weight and changes in femur bone mass and geometry were observed in the offspring at 5 mg/kg/day (approximately equal exposures (AUC) in humans at the 40 mg dose) and higher doses. The femur findings included lower total area, bone mineral content and density, periosteal and endosteal circumference, and cross-sectional moment of inertia. There were no microscopic changes in the distal femur, proximal tibia, or stifle joints. Changes in bone parameters were partially reversible following a recovery period, with findings on PND 70 limited to lower femur metaphysis cortical/subcortical bone mineral density in female pups at 5 mg/kg/day (approximately equal exposures (AUC) in humans at the 40 mg dose) and higher doses.

Lactation

Risk Summary

Pantoprazole has been detected in breast milk of a nursing mother after a single 40 mg oral dose of pantoprazole. There were no effects on the breastfed infant (see Data). There are no data on pantoprazole effects on milk production.

Data

Pediatric Use

The safety and effectiveness of PROTONIX for short-term treatment (up to eight weeks) of EE associated with GERD have been established in pediatric patients 1 year through 16 years of age. Effectiveness for EE has not been demonstrated in patients less than 1 year of age. In addition, for patients less than 5 years of age, there is no appropriate dosage strength in an age-appropriate formulation available. Therefore, PROTONIX is indicated for the short-term treatment of EE associated with GERD for patients 5 years and older. The safety and effectiveness of PROTONIX for pediatric uses other than EE have not been established.

1 Year Through 16 Years Of Age

Use of PROTONIX in pediatric patients 1 year through 16 years of age for short-term treatment (up to eight weeks) of EE associated with GERD is supported by: a) extrapolation of results from adequate and well-controlled studies that supported the approval of PROTONIX for treatment of EE associated with GERD in adults, and b) safety, effectiveness, and pharmacokinetic studies performed in pediatric patients [see Clinical Studies, CLINICAL PHARMACOLOGY].

Safety of PROTONIX in the treatment of EE associated with GERD in pediatric patients 1 through 16 years of age was evaluated in three multicenter, randomized, double-blind, parallel-treatment studies, involving 249 pediatric patients, including 8 with EE (4 patients ages 1 year to 5 years and 4 patients 5 years to 11 years). The children ages 1 year to 5 years with endoscopically diagnosed EE (defined as an endoscopic Hetzel-Dent score ≥2) were treated once daily for 8 weeks with one of two dose levels of PROTONIX (approximating 0.6 mg/kg or 1.2 mg/kg). All 4 of these patients with EE were healed (Hetzel-Dent score of 0 or 1) at 8 weeks. Because EE is uncommon in the pediatric population, predominantly pediatric patients with endoscopically-proven or symptomatic GERD were also included in these studies. Patients were treated with a range of doses of PROTONIX once daily for 8 weeks. For safety findings see ADVERSE REACTIONS. Because these pediatric trials had no placebo, active comparator, or evidence of a dose response, the trials were inconclusive regarding the clinical benefit of PROTONIX for symptomatic GERD in the pediatric population. The effectiveness of PROTONIX for treating symptomatic GERD in pediatric patients has not been established.

Although the data from the clinical trials support use of PROTONIX for the short-term treatment of EE associated with GERD in pediatric patients 1 year through 5 years, there is no commercially available dosage formulation appropriate for patients less than 5 years of age [see DOSAGE AND ADMINISTRATION].

Neonates To Less Than One Year Of Age

PROTONIX was not found to be effective in a multicenter, randomized, double-blind, placebo-controlled, treatment-withdrawal study of 129 pediatric patients 1 through 11 months of age. Patients were enrolled if they had symptomatic GERD based on medical history and had not responded to non-pharmacologic interventions for GERD for two weeks. Patients received PROTONIX daily for four weeks in an open-label phase, then patients were randomized in equal proportion to receive PROTONIX treatment or placebo for the subsequent four weeks in a double-blind manner. Efficacy was assessed by observing the time from randomization to study discontinuation due to symptom worsening during the four-week treatment-withdrawal phase. There was no statistically significant difference between PROTONIX and placebo in the rate of discontinuation.

In a population pharmacokinetic analysis, the systemic exposure was higher in patients less than 1 year of age with GERD compared to adults who received a single 40 mg dose (geometric mean AUC was 103% higher in preterm infants and neonates receiving single dose of 2.5 mg of PROTONIX, and 23% higher in infants 1 through 11 months of age receiving a single dose of approximately 1.2 mg/kg). In these patients, the apparent clearance (CL/F) increased with age (median clearance: 0.6 L/hr, range: 0.03 to 3.2 L/hr).

Because PROTONIX was not shown to be effective in the randomized, placebo-controlled study in this age group, the use of PROTONIX for treatment of symptomatic GERD in infants less than 1 year of age is not indicated.

Animal Toxicity Data

In a pre-and post-natal development study in rats, the pups were administered oral doses of pantoprazole at 5, 15, and 30 mg/kg/day (approximately 1, 2.3, and 3.2 times the exposure (AUC) in children aged 6 to 11 years at a dose of 40 mg) on postnatal day (PND 4) through PND 21, in addition to lactational exposure through milk. On PND 21, decreased mean femur length and weight and changes in femur bone mass and geometry were observed in the offspring at 5 mg/kg/day (approximately equal exposures (AUC) in children aged 6 to 11 years at the 40 mg dose) and higher doses. Changes in bone parameters were partially reversible following a recovery period.

In neonatal/juvenile animals (rats and dogs) toxicities were similar to those observed in adult animals, including gastric alterations, decreases in red cell mass, increases in lipids, enzyme induction and hepatocellular hypertrophy. An increased incidence of eosinophilic chief cells in adult and neonatal/juvenile rats, and atrophy of chief cells in adult rats and in neonatal/juvenile dogs, was observed in the fundic mucosa of stomachs in repeated-dose studies. Full to partial recovery of these effects were noted in animals of both age groups following a recovery period.

Geriatric Use

Overdosage & Contraindications

OVERDOSE

Experience in patients taking very high doses of PROTONIX (greater than 240 mg) is limited. Spontaneous post-marketing reports of overdose are generally within the known safety profile of PROTONIX.

Pantoprazole is not removed by hemodialysis. In case of overdosage, treatment should be symptomatic and supportive.

Single oral doses of pantoprazole at 709 mg/kg, 798 mg/kg, and 887 mg/kg were lethal to mice, rats, and dogs, respectively. The symptoms of acute toxicity were hypoactivity, ataxia, hunched sitting, limb-splay, lateral position, segregation, absence of ear reflex, and tremor.

If overexposure to PROTONIX occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage.

CONTRAINDICATIONS

PROTONIX is contraindicated in patients with known hypersensitivity to any component of the formulation or any substituted benzimidazole. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, and urticaria [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS].

Proton pump inhibitors (PPIs), including PROTONIX, are contraindicated in patients receiving rilpivirine-containing products [see DRUG INTERACTIONS].

CLINICAL PHARMACOLOGY

Mechanism Of Action

Pharmacodynamics

PROTONIX For Delayed-Release Oral Suspension, 40 mg has been shown to be comparable to PROTONIX Delayed-Release Tablets in suppressing pentagastrin-stimulated MAO in patients (n = 49) with GERD and a history of EE. In this multicenter, pharmacodynamic crossover study, a 40 mg oral dose of PROTONIX For Delayed-Release Oral Suspension administered in a teaspoonful of applesauce was compared with a 40 mg oral dose of PROTONIX Delayed-Release Tablets after administration of each formulation once daily for 7 days. Both medications were administered thirty minutes before breakfast. Pentagastrin-stimulated (MAO) was assessed from hour 23 to 24 at steady state.

Antisecretory Activity

Under maximal acid stimulatory conditions using pentagastrin, a dose-dependent decrease in gastric acid output occurs after a single dose of oral (20-80 mg) or a single dose of intravenous (20-120 mg) pantoprazole in healthy subjects. Pantoprazole given once daily results in increasing inhibition of gastric acid secretion. Following the initial oral dose of 40 mg pantoprazole, a 51% mean inhibition was achieved by 2.5 hours. With once-a-day dosing for 7 days, the mean inhibition was increased to 85%. Pantoprazole suppressed acid secretion in excess of 95% in half of the subjects. Acid secretion had returned to normal within a week after the last dose of pantoprazole; there was no evidence of rebound hypersecretion.

Table 5: Effect of Single Daily Doses of Oral Pantoprazole on Intragastric pH

Time

Median pH on day 7

* Significantly different from placebo# Significantly different from 20 mg

Serum Gastrin Effects

Fasting serum gastrin levels were assessed in two double-blind studies of the acute healing of EE in which 682 patients with gastroesophageal reflux disease (GERD) received 10, 20, or 40 mg of PROTONIX for up to 8 weeks. At 4 weeks of treatment there was an increase in mean gastrin levels of 7%, 35%, and 72% over pretreatment values in the 10, 20, and 40 mg treatment groups, respectively. A similar increase in serum gastrin levels was noted at the 8-week visit with mean increases of 3%, 26%, and 84% for the three pantoprazole dose groups. Median serum gastrin levels remained within normal limits during maintenance therapy with PROTONIX Delayed-Release Tablets.

In long-term international studies involving over 800 patients, a 2-to 3-fold mean increase from the pretreatment fasting serum gastrin level was observed in the initial months of treatment with pantoprazole at doses of 40 mg per day during GERD maintenance studies and 40 mg or higher per day in patients with refractory GERD. Fasting serum gastrin levels generally remained at approximately 2 to 3 times baseline for up to 4 years of periodic follow-up in clinical trials.

Following short-term treatment with PROTONIX, elevated gastrin levels return to normal by at least 3 months.

Enterochromaffin-Like (ECL) Cell Effects

In 39 patients treated with oral pantoprazole 40 mg to 240 mg daily (majority receiving 40 mg to 80 mg) for up to 5 years, there was a moderate increase in ECL-cell density, starting after the first year of use, which appeared to plateau after 4 years.

In a nonclinical study in Sprague-Dawley rats, lifetime exposure (24 months) to pantoprazole at doses of 0.5 to 200 mg/kg/day resulted in dose-related increases in gastric ECL-cell proliferation and gastric neuroendocrine (NE)-cell tumors. Gastric NE-cell tumors in rats may result from chronic elevation of serum gastrin concentrations. The high density of ECL cells in the rat stomach makes this species highly susceptible to the proliferative effects of elevated gastrin concentrations produced by PPIs. However, there were no observed elevations in serum gastrin following the administration of pantoprazole at a dose of 0.5 mg/kg/day. In a separate study, a gastric NE-cell tumor without concomitant ECL-cell proliferative changes was observed in 1 female rat following 12 months of dosing with pantoprazole at 5 mg/kg/day and a 9 month off-dose recovery [see Nonclinical Toxicology].

Endocrine Effects

In a clinical pharmacology study, PROTONIX 40 mg given once daily for 2 weeks had no effect on the levels of the following hormones: cortisol, testosterone, triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH), thyronine-binding protein, parathyroid hormone, insulin, glucagon, renin, aldosterone, follicle-stimulating hormone, luteinizing hormone, prolactin, and growth hormone.

In a 1-year study of GERD patients treated with PROTONIX 40 mg or 20 mg, there were no changes from baseline in overall levels of T3, T4, and TSH.

Pharmacokinetics

PROTONIX Delayed-Release Tablets are prepared as enteric-coated tablets so that absorption of pantoprazole begins only after the tablet leaves the stomach. Peak serum concentration (Cmax) and area under the serum concentration time curve (AUC) increase in a manner proportional to oral and intravenous doses from 10 mg to 80 mg. Pantoprazole does not accumulate, and its pharmacokinetics are unaltered with multiple daily dosing. Following oral or intravenous administration, the serum concentration of pantoprazole declines biexponentially, with a terminal elimination half-life of approximately one hour.

In extensive metabolizers with normal liver function receiving an oral dose of the enteric-coated 40 mg pantoprazole tablet, the peak concentration (Cmax) is 2.5 μg/mL; the time to reach the peak concentration (tmax) is 2.5 h, and the mean total area under the plasma concentration versus time curve (AUC) is 4.8 μg•h/mL (range 1.4 to 13.3 μg•h/mL). Following intravenous administration of pantoprazole to extensive metabolizers, its total clearance is 7.6-14.0 L/h, and its apparent volume of distribution is 11.0-23.6 L.

A single oral dose of PROTONIX For Delayed-Release Oral Suspension, 40 mg, was shown to be bioequivalent when administered to healthy subjects (N = 22) as granules sprinkled over a teaspoonful of applesauce, as granules mixed with apple juice, or mixed with apple juice followed by administration through a nasogastric tube. The plasma pharmacokinetic parameters from a crossover study in healthy subjects are summarized in Table 6.

Table 6: Pharmacokinetics Parameters (mean ± SD) of PROTONIX For Delayed-Release Oral Suspension at 40 mg

Absorption

After administration of a single or multiple oral 40 mg doses of PROTONIX Delayed-Release Tablets, the peak plasma concentration of pantoprazole was achieved in approximately 2.5 hours, and Cmax was 2.5 μg/mL. Pantoprazole undergoes little first-pass metabolism, resulting in an absolute bioavailability of approximately 77%. Pantoprazole absorption is not affected by concomitant administration of antacids.

Administration of PROTONIX Delayed-Release Tablets with food may delay its absorption up to 2 hours or longer; however, the Cmax and the extent of pantoprazole absorption (AUC) are not altered. Thus, PROTONIX Delayed-Release Tablets may be taken without regard to timing of meals.

Administration of pantoprazole granules, 40 mg, with a high-fat meal delayed median time to peak plasma concentration by 2 hours. With a concomitant high-fat meal, the Cmax and AUC of pantoprazole granules, 40 mg, sprinkled on applesauce decreased by 51% and 29%, respectively. Thus, PROTONIX For Delayed-Release Oral Suspension should be taken approximately 30 minutes before a meal.

Distribution

The apparent volume of distribution of pantoprazole is approximately 11 to 23.6 L, distributing mainly in extracellular fluid. The serum protein binding of pantoprazole is about 98%, primarily to albumin.

Elimination

Metabolism

Pantoprazole is extensively metabolized in the liver through the cytochrome P450 (CYP) system. Pantoprazole metabolism is independent of the route of administration (intravenous or oral). The main metabolic pathway is demethylation, by CYP2C19, with subsequent sulfation; other metabolic pathways include oxidation by CYP3A4. There is no evidence that any of the pantoprazole metabolites have significant pharmacologic activity.

Excretion

After a single oral or intravenous dose of 14C-labeled pantoprazole to healthy, normal metabolizer subjects, approximately 71% of the dose was excreted in the urine, with 18% excreted in the feces through biliary excretion. There was no renal excretion of unchanged pantoprazole.

Specific Populations

Geriatric Patients

Only slight to moderate increases in the AUC (43%) and Cmax (26%) of pantoprazole were found in elderly subjects (64 to 76 years of age) after repeated oral administration, compared with younger subjects [see Use In Specific Populations].

Pediatric Patients

The pharmacokinetics of pantoprazole were studied in children less than 16 years of age in four randomized, open-label clinical trials in pediatric patients with presumed/proven GERD. A pediatric granule formulation was studied in children through 5 years of age, and PROTONIX Delayed-Release Tablets were studied in children older than 5 years.

In a population PK analysis, total clearance increased with increasing bodyweight in a non-linear fashion. The total clearance also increased with increasing age only in children under 3 years of age.

Neonate Through 5 Years Of Age

[see Use In Specific Populations]

Children And Adolescents 6 Through 16 Years Of Age

The pharmacokinetics of PROTONIX Delayed-Release Tablets were evaluated in children ages 6 through 16 years with a clinical diagnosis of GERD. The PK parameters following a single oral dose of 20 mg or 40 mg of PROTONIX tablets in children ages 6 through 16 years were highly variable (%CV ranges 40 to 80%). The geometric mean AUC estimated from population PK analysis after a 40 mg PROTONIX tablet in pediatric patients was about 39% and 10% higher respectively in 6 to 11 and 12 to 16 year-old children, compared to that of adults (Table 7).

Table 7: PK Parameters in Children and Adolescents 6 through 16 years with GERD receiving 40 mg PROTONIX Tablets

6-11 years(n=12)

12-16 years(n=11)

Cmax (μg/mL) a

1.8

1.8

tmax (h) b

2.0

2.0

AUC (μg*h/mL) a

6.9

5.5

CL/F (L/h) b

6.6

6.8

a Geometric mean valuesb Median values

Male And Female Patients

There is a modest increase in pantoprazole AUC and Cmax in women compared to men. However, weight-normalized clearance values are similar in women and men.

In pediatric patients ages 1 through 16 years there were no clinically relevant effects of gender on clearance of pantoprazole, as shown by population pharmacokinetic analysis.

Patients With Renal Impairment

In patients with severe renal impairment, pharmacokinetic parameters for pantoprazole were similar to those of healthy subjects.

Patients With Hepatic Impairment

In patients with mild to severe hepatic impairment (Child-Pugh A to C cirrhosis), maximum pantoprazole concentrations increased only slightly (1.5-fold) relative to healthy subjects. Although serum half-life values increased to 7-9 hours and AUC values increased by 5-to 7-fold in hepatic- impaired patients, these increases were no greater than those observed in CYP2C19 poor metabolizers, where no dosage adjustment is warranted. These pharmacokinetic changes in hepatic-impaired patients result in minimal drug accumulation following once-daily, multiple-dose administration. Doses higher than 40 mg/day have not been studied in hepatically impaired patients.

Drug Interaction Studies

Effect Of Other Drugs On Pantoprazole

Pantoprazole is metabolized mainly by CYP2C19 and to minor extents by CYPs 3A4, 2D6, and 2C9. In in vivo drug-drug interaction studies with CYP2C19 substrates (diazepam [also a CYP3A4 substrate] and phenytoin [also a CYP3A4 inducer] and clopidogrel), nifedipine, midazolam, and clarithromycin (CYP3A4 substrates), metoprolol (a CYP2D6 substrate), diclofenac, naproxen and piroxicam (CYP2C9 substrates), and theophylline (a CYP1A2 substrate) in healthy subjects, the pharmacokinetics of pantoprazole were not significantly altered.

Effect Of Pantoprazole On Other Drugs

Clopidogrel

Clopidogrel is metabolized to its active metabolite in part by CYP2C19. In a crossover clinical study, 66 healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day) alone and with pantoprazole (80 mg at the same time as clopidogrel) for 5 days. On Day 5, the mean AUC of the active metabolite of clopidogrel was reduced by approximately 14% (geometric mean ratio was 86%, with 90% CI of 79 to 93%) when pantoprazole was coadministered with clopidogrel as compared to clopidogrel administered alone. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation (induced by 5 μM ADP) was correlated with the change in the exposure to clopidogrel active metabolite. The clinical significance of this finding is not clear.

Mycophenolate Mofetil (MMF)

Administration of pantoprazole 40 mg twice daily for 4 days and a single 1000 mg dose of MMF approximately one hour after the last dose of pantoprazole to 12 healthy subjects in a cross-over study resulted in a 57% reduction in the Cmax and 27% reduction in the AUC of MPA. Transplant patients receiving approximately 2000 mg per day of MMF (n=12) were compared to transplant patients receiving approximately the same dose of MMF and pantoprazole 40 mg per day (n=21). There was a 78% reduction in the Cmax and a 45% reduction in the AUC of MPA in patients receiving both pantoprazole and MMF [see DRUG INTERACTIONS].

Other Drugs

In vivo studies also suggest that pantoprazole does not significantly affect the kinetics of the following drugs (cisapride, theophylline, diazepam [and its active metabolite, desmethyldiazepam], phenytoin, metoprolol, nifedipine, carbamazepine, midazolam, clarithromycin, diclofenac, naproxen, piroxicam, and oral contraceptives [ levonorgestrel/ethinyl estradiol]). In other in vivo studies, digoxin, ethanol, glyburide, antipyrine, caffeine, metronidazole, and amoxicillin had no clinically relevant interactions with pantoprazole.

Although no significant drug-drug interactions have been observed in clinical studies, the potential for significant drug-drug interactions with more than once-daily dosing with high doses of pantoprazole has not been studied in poor metabolizers or individuals who are hepatically impaired.

Antacids

There was also no interaction with concomitantly administered antacids.

Pharmacogenomics

CYP2C19 displays a known genetic polymorphism due to its deficiency in some subpopulations (e.g., approximately 3% of Caucasians and African-Americans and 17% to 23% of Asians are poor metabolizers). Although these subpopulations of pantoprazole poor metabolizers have elimination half-life values of 3.5 to 10 hours in adults, they still have minimal accumulation (23% or less) with once-daily dosing. For adult patients who are CYP2C19 poor metabolizers, no dosage adjustment is needed.

Similar to adults, pediatric patients who have the poor metabolizer genotype of CYP2C19 (CYP2C19 *2/*2) exhibited greater than a 6-fold increase in AUC compared to pediatric extensive (CYP2C19 *1/*1) and intermediate (CYP2C19 *1/*x) metabolizers. Poor metabolizers exhibited approximately 10-fold lower apparent oral clearance compared to extensive metabolizers.

For known pediatric poor metabolizers, a dose reduction should be considered.

Clinical Studies

PROTONIX Delayed-Release Tablets were used in the following clinical trials.

Erosive Esophagitis (EE) Associated With Gastroesophageal Reflux Disease (GERD)

Adult Patients

A US multicenter, double-blind, placebo-controlled study of PROTONIX 10 mg, 20 mg, or 40 mg once daily was conducted in 603 patients with reflux symptoms and endoscopically diagnosed EE of grade 2 or above (Hetzel-Dent scale). In this study, approximately 25% of enrolled patients had severe EE of grade 3, and 10% had grade 4. The percentages of patients healed (per protocol, n = 541) in this study are shown in Table 8.

Table 8: Erosive Esophagitis Healing Rates (Per Protocol)

In this study, all PROTONIX treatment groups had significantly greater healing rates than the placebo group. This was true regardless of H. pylori status for the 40 mg and 20 mg PROTONIX treatment groups. The 40 mg dose of PROTONIX resulted in healing rates significantly greater than those found with either the 20 mg or 10 mg dose.

A significantly greater proportion of patients taking PROTONIX 40 mg experienced complete relief of daytime and nighttime heartburn and the absence of regurgitation, starting from the first day of treatment, compared with placebo. Patients taking PROTONIX consumed significantly fewer antacid tablets per day than those taking placebo.

PROTONIX 40 mg and 20 mg once daily were also compared with nizatidine 150 mg twice daily in a US multicenter, double-blind study of 243 patients with reflux symptoms and endoscopically diagnosed EE of grade 2 or above. The percentages of patients healed (per protocol, n = 212) are shown in Table 9.

Table 9: Erosive Esophagitis Healing Rates (Per Protocol)

Once-daily treatment with PROTONIX 40 mg or 20 mg resulted in significantly superior rates of healing at both 4 and 8 weeks compared with twice-daily treatment with 150 mg of nizatidine. For the 40 mg treatment group, significantly greater healing rates compared to nizatidine were achieved regardless of the H. pylori status.

A significantly greater proportion of the patients in the PROTONIX treatment groups experienced complete relief of nighttime heartburn and regurgitation, starting on the first day and of daytime heartburn on the second day, compared with those taking nizatidine 150 mg twice daily. Patients taking PROTONIX consumed significantly fewer antacid tablets per day than those taking nizatidine.

Pediatric Patients Ages 5 Years Through 16 Years

The efficacy of PROTONIX in the treatment of EE associated with GERD in pediatric patients ages 5 years through 16 years is extrapolated from adequate and well-conducted trials in adults, as the pathophysiology is thought to be the same. Four pediatric patients with endoscopically diagnosed EE were studied in multicenter, randomized, double-blind, parallel-treatment trials. Children with endoscopically diagnosed EE (defined as an endoscopic Hetzel-Dent score ≥2) were treated once daily for 8 weeks with one of two dose levels of PROTONIX (20 mg or 40 mg). All 4 patients with EE were healed (Hetzel-Dent score of 0 or 1) at 8 weeks.

Long-Term Maintenance Of Healing Of Erosive Esophagitis

Two independent, multicenter, randomized, double-blind, comparator-controlled trials of identical design were conducted in adult GERD patients with endoscopically confirmed healed EE to demonstrate efficacy of PROTONIX in long-term maintenance of healing. The two US studies enrolled 386 and 404 patients, respectively, to receive either 10 mg, 20 mg, or 40 mg of PROTONIX Delayed-Release Tablets once daily or 150 mg of ranitidine twice daily. As demonstrated in Table 10, PROTONIX 40 mg and 20 mg were significantly superior to ranitidine at every timepoint with respect to the maintenance of healing. In addition, PROTONIX 40 mg was superior to all other treatments studied.

Table 10: Long-Term Maintenance of Healing of Erosive Gastroesophageal Reflux Disease (GERD Maintenance): Percentage of Patients Who Remained Healed

* (p <0.05 vs. ranitidine)# (p <0.05 vs. PROTONIX 20 mg)Note: PROTONIX 10 mg was superior (p <0.05) to ranitidine in Study 2, but not Study 1.

PROTONIX 40 mg was superior to ranitidine in reducing the number of daytime and nighttime heartburn episodes from the first through the twelfth month of treatment. PROTONIX 20 mg, administered once daily, was also effective in reducing episodes of daytime and nighttime heartburn in one trial, as presented in Table 11.

Table 11: Number of Episodes of Heartburn (mean ± SD)

*(p <0.001 vs. ranitidine, combined data from the two US studies)

Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome

In a multicenter, open-label trial of 35 patients with pathological hypersecretory conditions, such as Zollinger-Ellison Syndrome, with or without multiple endocrine neoplasia-type I, PROTONIX successfully controlled gastric acid secretion. Doses ranging from 80 mg daily to 240 mg daily maintained gastric acid output below 10 mEq/h in patients without prior acid-reducing surgery and below 5 mEq/h in patients with prior acid-reducing surgery.

Doses were initially titrated to the individual patient needs, and adjusted in some patients based on the clinical response with time [see DOSAGE AND ADMINISTRATION]. PROTONIX was well tolerated at these dose levels for prolonged periods (greater than 2 years in some patients).

PATIENT INFORMATION

PROTONIX(pro-TAH-nix)(pantoprazole sodium) delayed-release tablets and PROTONIX (pro-TAH-nix) (pantoprazole sodium) for delayed-release oral suspension

What is the most important information I should know about PROTONIX? You should take PROTONIX exactly as prescribed, at the lowest dose possible and for the shortest time needed.

PROTONIX may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.

PROTONIX can cause serious side effects, including:

A type of kidney problem (acute tubulointerstitial nephritis). Some people who take proton pump inhibitor (PPI) medicines, including PROTONIX, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with PROTONIX. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine.

Diarrhea caused by an infection (Clostridium difficile) in your intestines. Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever.

Bone fractures (hip, wrist, or spine). Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine.

Certain types of lupus erythematosus. Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including PROTONIX, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.

Talk to your doctor about your risk of these serious side effects.

PROTONIX can have other serious side effects. See “What are the possible side effects of PROTONIX?”

What is PROTONIX?

A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach.

In adults, PROTONIX is used for:

up to 8 weeks for the healing and symptom relief of acid-related damage to the lining of the esophagus (called erosive esophagitis or EE). Your doctor may prescribe another 8 weeks of PROTONIX in patients whose EE does not heal.

maintaining healing of EE and to help prevent the return of heartburn symptoms caused by GERD. It is not known if PROTONIX is safe and effective when used for longer than 12 months for this purpose.

the long-term treatment of conditions where your stomach makes too much acid. This includes a rare condition called Zollinger-Ellison Syndrome.

In children 5 years of age and older, PROTONIX is used for:

up to 8 weeks for the healing and symptom relief of EE. It is not known if PROTONIX is safe if used longer than 8 weeks in children.

PROTONIX is not for use in children under 5 years of age. It is not known if PROTONIX is safe and effective in children for treatment other than EE.

Do not take PROTONIX if you are:

allergic to pantoprazole sodium, any other PPI medicine, or any of the ingredients in PROTONIX. See the end of this Medication Guide for a complete list of ingredients.

taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY, JULUCA) used to treat HIV-1 (Human Immunodeficiency Virus).

Before taking PROTONIX, tell your doctor about all of your medical conditions, including if you:

have low magnesium levels in your blood.

are pregnant or plan to become pregnant. PROTONIX may harm your unborn baby. Tell your doctor if you become pregnant or think you may be pregnant during treatment with PROTONIX.

are breastfeeding or plan to breastfeed. PROTONIX can pass into your breast milk. Talk with your doctor about the best way to feed your baby if you take PROTONIX.

Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. Especially tell your doctor if you take methotrexate (Otrexup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), or a water pill ( diuretic).

How should I take PROTONIX?

Take PROTONIX exactly as prescribed by your doctor.

PROTONIX delayed-release tablets (PROTONIX tablets):

Do not split, chew, or crush PROTONIX tablets.

Swallow PROTONIX tablets whole, with or without food.

Tell your doctor if you are not able to swallow your PROTONIX tablet.

You may use antacids while taking PROTONIX tablets.

PROTONIX for delayed-release oral suspension (PROTONIX for oral suspension):

Do not split, chew, or crush PROTONIX for oral suspension.

Take PROTONIX for oral suspension about 30 minutes before a meal.

PROTONIX for oral suspension should only be given by mouth mixed in apple juice or applesauce or through a nasogastric (NG) tube or gastrostomy tube mixed in apple juice. Do not mix PROTONIX for oral suspension in liquids other than apple juice or foods other than applesauce.

Do not divide a packet of PROTONIX for oral suspension to make a smaller dose.

See the “Instructions for Use” at the end of this Medication Guide for instructions on how to mix and take PROTONIX for oral suspension by mouth in applesauce or apple juice or how to mix and give the suspension through an NG tube or gastrostomy tube mixed in apple juice.

If you miss a dose of PROTONIX, take it as soon as possible. If it is almost time for your next dose, do not take the missed dose. Take the next dose at your regular time. Do not take 2 doses at the same time.

If you take too much PROTONIX, call your doctor or your poison control center at 1-800-222-1222 right away or go to the nearest emergency room.

What are the possible side effects of PROTONIX? PROTONIX can cause serious side effects, including:

See “What is the most important information I should know about PROTONIX?”

Low vitamin B-12 levels in your body can happen in people who have taken PROTONIX for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs.

Low magnesium levels in your body can happen in people who have taken PROTONIX for at least 3 months. Tell your doctor if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice.

Stomach growths (fundic gland polyps). People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year.

The most common side effects of PROTONIX in adults include: headache, diarrhea, nausea, stomach-area (abdominal) pain, vomiting, gas, dizziness, and joint pain.

How should I store PROTONIX?

Store PROTONIX at room temperature between 68°F to 77°F (20°C to 25°C).

Keep PROTONIX and all medicines out of the reach of children. General information about the safe and effective use of PROTONIX.

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use PROTONIX for a condition for which it was not prescribed. Do not give PROTONIX to other people, even if they have the same symptoms that you have. It may harm them. You can ask your doctor or pharmacist for information about PROTONIX that is written for health professionals.

What are the ingredients in PROTONIX?

Active ingredient: pantoprazole sodium sesquihydrate

Inactive ingredients in PROTONIX delayed-release tablets: calcium stearate, crospovidone, hypromellose, iron oxide, mannitol, methacrylic acid copolymer, polysorbate 80, povidone, propylene glycol, sodium carbonate, sodium lauryl sulfate, titanium dioxide, and triethyl citrate.

Inactive ingredients in PROTONIX for delayed-release oral suspension: crospovidone, hypromellose, methacrylic acid copolymer, microcrystalline cellulose, polysorbate 80, povidone, sodium carbonate, sodium lauryl sulfate, talc, titanium dioxide, triethyl citrate, and yellow ferric oxide.

Instructions for Use

PROTONIX(pro-TAH-nix) (pantoprazole sodium) for delayed-release oral suspension

PROTONIX for delayed-release oral suspension (PROTONIX for oral suspension):

Important information:

Do not split, chew, or crush PROTONIX for oral suspension.

Take PROTONIX for oral suspension about 30 minutes before a meal.

PROTONIX for oral suspension:

should only be taken with applesauce or apple juice.

should not be mixed in water or other liquids, or other foods.

packet should not be divided to make a smaller dose.

Taking PROTONIX for oral suspension with applesauce:

Open the packet of PROTONIX for oral suspension.

Sprinkle all of the granules in the packet on 1 teaspoon of applesauce.

Swallow the granules and applesauce within 10 minutes of putting the granules on the teaspoon of applesauce.

Take sips of water to make sure the granules are washed down into the stomach. Take more sips of water as needed.

Taking PROTONIX for oral suspension with apple juice:

Open the packet of PROTONIX for oral suspension.

Empty all of the granules in the packet into a small cup that contains 1 teaspoon of apple juice.

Stir the granules-apple juice mixture for 5 seconds. The granules will not break up.

Swallow the mixture right away.

To make sure that the entire dose is taken, add more apple juice to the cup, stir and swallow the apple juice right away.

Repeat step 5 if there are granules left in the cup.

Giving PROTONIX for oral suspension through a nasogastric (NG) tube or gastrostomy tube:

PROTONIX for oral suspension may be given through an NG tube or gastrostomy tube that is size 16 French or larger. Do not give PROTONIX for oral suspension through an NG tube or gastrostomy tube smaller than size 16 French.

Mix PROTONIX for oral suspension only in apple juice when giving through an NG tube or gastrostomy tube.

How should I store PROTONIX?

Remove the plunger from a 60 mL (2 ounce) catheter-tip syringe. Throw away the plunger.

Connect the tip of the catheter-tip syringe to the NG tube or gastrostomy tube.

Hold the syringe attached to the NG tube or gastrostomy tube as high as possible while giving PROTONIX for oral suspension to prevent the tubing from bending.

Open the packet of PROTONIX for oral suspension.

Empty all the granules in the packet into the catheter-tip syringe.

Add 10 mL (2 teaspoons) of apple juice into the catheter-tip syringe and gently tap or shake the syringe to help empty the syringe.

Repeat step 6 at least 2 more times until there are no granules left in the catheter-tip syringe.

Keep PROTONIX and all medicines out of the reach of children.

Store PROTONIX at room temperature between 68°F to 77°F (20°C to 25°C).

This Medication Guide and Instructions for Use has been approved by the U.S. Food and Drug Administration.

Polysaccharide Iron Complex Oral: Uses, Side Effects, Interactions, Pictures, Warnings &Amp; Dosing / 2023

Follow all directions on the product package, or take as directed by your doctor. Do not take more than the recommended dosage. If you have any questions, ask your doctor or pharmacist.

Iron is best absorbed on an empty stomach (usually if taken 1 hour before or 2 hours after meals). If stomach upset occurs, you may take this medication with food. See the instructions below for the liquid drops for infants/children. Avoid taking antacids, dairy products, tea, or coffee within 2 hours before or after this medication because they will decrease its effectiveness.

Take tablets or capsules with a full glass of water (8 ounces or 240 milliliters) unless otherwise directed by your doctor. Do not lie down for at least 10 minutes after taking your tablet or capsule dose.

Swallow extended-release capsules whole. Do not crush or chew extended-release capsules or tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Also, do not split extended-release tablets unless they have a score line and your doctor or pharmacist tells you to do so. Swallow the whole or split tablet without crushing or chewing.

If you are taking chewable tablets, chew the medication thoroughly, then swallow.

If you are taking a liquid suspension form of this medication, shake the bottle well before each dose.

If you are taking the liquid form for adults, carefully measure the dose using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose. Mix the dose in a glass of water or juice, and drink the mixture through a straw to prevent staining the teeth.

If you are giving the liquid drops to an infant or child, use the dropper provided to carefully measure the dose. The dose may be placed directly into the mouth (towards the back of the tongue) or it may be mixed in formula (not milk), fruit juice, cereal, or other food as directed to increase your child’s acceptance. It is best to give this medication right after a meal. Follow the directions on the product package for the brand that you use.

Take this medication regularly in order to get the most benefit from it. To help you remember, take it at the same time(s) each day.

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