Is there evidence to support twice daily (bid) pantoprazole (proton pump inhibitor) instead of once daily dosing in a patient with severe untreated gastroesophageal reflux disease (GERD) and acute pancreatitis?

From the Guidelines

In patients with severe untreated reflux and acute pancreatitis, starting with bid pantoprazole may be considered, but the current evidence suggests that standard pantoprazole dosing of 40mg once daily is typically sufficient for most patients with gastroesophageal reflux disease (GERD), even in the setting of acute pancreatitis. According to the most recent guidelines, clinicians should provide a 4- to 8-week trial of single-dose PPI therapy, and with inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day 1. The theoretical benefit of BID dosing is more consistent acid suppression throughout a 24-hour period, which could be particularly important in acute pancreatitis where minimizing acid reflux may help reduce pancreatic stimulation and inflammation.

Some key points to consider when deciding on the dosing regimen include:

• Pantoprazole reaches steady-state plasma levels within 3 days, so either regimen should be continued for at least this duration to achieve full effect 1.
• It's essential to administer pantoprazole 30-60 minutes before meals for optimal efficacy.
• If using BID dosing, consider 40mg before breakfast and 40mg before dinner.
• Monitor for improvement in both reflux symptoms and pancreatitis parameters, and once the acute phase resolves, consider stepping down to once-daily dosing for maintenance therapy.

The decision to use BID dosing should be based on the individual patient's response to treatment and the severity of their symptoms, rather than a one-size-fits-all approach. As stated in the guidelines, the main identifiable risk associated with reducing or discontinuing PPI therapy is an increased symptom burden, and the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient’s quality of life rather than as a disease control measure 1.

From the Research

Treatment of Acute Pancreatitis

• The provided studies do not directly address the question of whether to start bid pantoprazole instead of daily dosing in a patient with severe untreated reflux and acute pancreatitis 2, 3, 4, 5, 6.
• However, it is noted that pantoprazole can be associated with acute pancreatitis as an adverse drug reaction, as seen in a case report of an 11-year-old boy 2.
• The management of acute pancreatitis typically involves supportive therapy, including fluid resuscitation, enteral feeding, and analgesia 3, 4, 5, 6.
• There is no mention of the specific use of bid pantoprazole in the treatment of acute pancreatitis in the provided studies.
• The American College of Gastroenterology Guidelines and other studies emphasize the importance of early management, nutrition, and prevention of complications in acute pancreatitis 4, 5, 6.

Use of Pantoprazole

• Pantoprazole is a proton pump inhibitor that can be used to treat gastroesophageal reflux disease (GERD) 2.
• However, the use of pantoprazole in patients with acute pancreatitis is not well-established, and its potential to cause acute pancreatitis as an adverse drug reaction should be considered 2.
• The provided studies do not provide evidence to support the use of bid pantoprazole instead of daily dosing in patients with severe untreated reflux and acute pancreatitis.