From the FDA Drug Label
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 to 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 Administration of rabeprazole sodium delayed-release tablets to patients with mild to moderate hepatic impairment (Child-Pugh Class A and B, respectively) resulted in increased exposure and decreased elimination. No dosage adjustment is necessary in patients with mild to moderate hepatic impairment. There is no information in patients with severe hepatic impairment (Child-Pugh Class C) Avoid use of rabeprazole sodium delayed-release tablets in patients with severe hepatic impairment; however, if treatment is necessary, monitor patients for adverse reactions
- Pantoprazole can be given in patients with deranged liver enzymes, with a maximum increase of 1.5-fold in concentrations and 5- to 7-fold increase in AUC values in hepatic-impaired patients.
- Rabeprazole can be given in patients with mild to moderate hepatic impairment, but its use should be avoided in patients with severe hepatic impairment.
- Monitoring is recommended when using rabeprazole in patients with severe hepatic impairment if treatment is necessary.
- Dosage adjustment is not necessary for pantoprazole in hepatic-impaired patients, and it is also not necessary for rabeprazole in patients with mild to moderate hepatic impairment 1 2.
From the Research
Rabeprazole is generally preferred over pantoprazole in patients with deranged liver enzymes due to its non-enzymatic metabolism, which makes it less dependent on liver function for elimination. According to the most recent and highest quality study 3, pantoprazole and rabeprazole do not have a significant impact on microsomal activity in patients with cirrhosis, whereas other proton pump inhibitors (PPIs) such as omeprazole, esomeprazole, and lansoprazole inhibit microsomal activity. The standard dose of rabeprazole (20 mg daily) typically doesn't require adjustment in patients with hepatic impairment. Pantoprazole, while also considered relatively safe, undergoes more hepatic metabolism and may require dose reduction in severe liver disease. For pantoprazole in patients with severe hepatic impairment, the dose should not exceed 20 mg daily, and liver enzymes should be monitored regularly during treatment. Both medications effectively reduce gastric acid production by inhibiting the proton pump in gastric parietal cells. Some key points to consider when choosing between these medications include:
- The severity of liver dysfunction
- The potential for drug interactions
- The patient's individual response to the medication It's also important to note that the use of PPIs in cirrhotic patients has been associated with the development of infections and hepatic encephalopathy and should be carefully considered, as stated in the study 4. Overall, the choice between pantoprazole and rabeprazole should be based on the individual patient's needs and medical history, with rabeprazole offering a slight advantage in patients with significant hepatic impairment due to its non-liver dependent clearance pathway.