A 62‑year‑old man with COPD exacerbation, hypertension, and hyperlipidemia who was intubated has been weaned from mechanical ventilation, is now on low‑flow nasal cannula, has passed a formal swallow evaluation, is tolerating an oral diet, and is receiving intravenous pantoprazole for stress‑ulcer prophylaxis. What is the appropriate next step for his pantoprazole therapy?

Discontinue Intravenous Pantoprazole and Switch to Oral Pantoprazole

You should discontinue intravenous pantoprazole and switch to oral pantoprazole immediately. This patient has been extubated, passed a formal swallow evaluation, is tolerating an oral diet, and no longer requires IV access for stress ulcer prophylaxis 1.

Rationale for Switching from IV to Oral

• The FDA label for IV pantoprazole explicitly states: "Discontinue treatment with Pantoprazole Sodium for Injection as soon as the patient is able to receive treatment with pantoprazole sodium delayed-release tablets or oral suspension" 1.

• This patient meets all criteria for oral administration: he is extubated, has passed a formal swallow evaluation, is tolerating oral diet, and is on the medical floor 1.

• Oral pantoprazole 40 mg once daily provides equivalent acid suppression to IV pantoprazole 40 mg once daily, with no dosage adjustment required when switching between formulations 2.

• The oral bioavailability of pantoprazole is 77%, ensuring adequate systemic exposure when the enteral route is functional 3.

Rationale for Continuing (Not Discontinuing) Stress Ulcer Prophylaxis

• The 2016 Surviving Sepsis Campaign guidelines recommend stress ulcer prophylaxis for patients with sepsis or septic shock who have risk factors for gastrointestinal bleeding 4.

• This patient has multiple ongoing risk factors that justify continued prophylaxis:

  • Mechanical ventilation for 3 days (a well-established risk factor for stress ulceration) 4
  • Systemic corticosteroids (prednisone IV, which increases bleeding risk) 4
  • Severe acute illness (COPD exacerbation requiring intubation) 4

• Although he is now extubated and on 4 L nasal cannula, he remains acutely ill on systemic corticosteroids and has not yet been discharged from the hospital—conditions that warrant ongoing prophylaxis 4.

• The guidelines recommend continuing stress ulcer prophylaxis in patients without risk factors should not receive prophylaxis, but this patient clearly has risk factors 4.

Practical Transition Protocol

• Switch to oral pantoprazole 40 mg once daily starting with the next scheduled dose; there is no need for dose overlap or titration 2.

• Oral pantoprazole maintains the same degree of acid suppression as IV pantoprazole, so therapeutic continuity is preserved 2, 5.

• Administer the oral dose in the morning before breakfast for optimal absorption, though food does not significantly affect bioavailability 3.

Duration of Therapy Post-Transition

• Continue oral pantoprazole until the patient is discharged from the hospital and systemic corticosteroids are discontinued 4.

• Reassess the need for ongoing acid suppression at discharge; if the patient has no chronic indication (e.g., GERD, peptic ulcer disease), pantoprazole should be discontinued at that time 4.

• Do not continue stress ulcer prophylaxis indefinitely after hospital discharge in the absence of a separate indication 4.

Common Pitfalls to Avoid

• Do not continue IV pantoprazole once the patient can take oral medications—this wastes resources, prolongs IV access (with attendant infection risk), and contradicts FDA labeling 1.

• Do not discontinue all acid suppression abruptly while the patient remains on systemic corticosteroids and is still hospitalized—he retains risk factors for stress ulceration 4.

• Do not use H2-receptor antagonists instead of a proton pump inhibitor in this setting—the 2016 Surviving Sepsis guidelines suggest either agent is acceptable, but this patient is already on a PPI and switching drug classes offers no advantage 4.