To the Editor:
Pantoprazole (Protonix; Wyeth Laboratories, Philadelphia, PA ), the fourth benzimidazole proton pump inhibitor to become available in the United States, has been marked for short-term oral treatment of erosive gastroesophageal reflux diseases (GERD). 1 In a published 8-week study in patients with erosive GERD, complete healing occurred in 153 (90%) of 170 patients treated with pantoprazole 40 mg/d and in 81 (94%) of 86 patients treated with omeprazole 20 mg/d. 2 Pantoprazole was more effective than the H2-recptor antagonist ranitidine (Zantac; GlaxoSmithKline, Research Triangle Park, NC) and others in healing esophageal erosions and decreasing symptoms of GERD. 3 Thus far, pantoprazole is the only proton pump inhibitor that can be used intravenously in the U.S. market. In a recent study, it is reported that oral and intravenous pantoprazole are equal in their ability to suppress gastric acid secretion 4; however, little information is available about the effectiveness of intravenous pantoprazole for erosive GERD. We observed healing of erosive esophagitis with intravenous pantoprazole in several patients in less than 1 week.
We recently start using intravenous pantoprazole in our hospital to treat patients with erosive esophagitis and stricture who are unable to take the oral formulation. We observed four patients who were treated with intravenous pantoprazole for severe esophagitis and stricture and in whom esophagitis healed in less than 1 week. One such patient was a 42-year-old woman with multiple medical problems, including a necrotic cecum for which she underwent emergent resection and an end-ileostomy. She recovered from her surgeries and was discharged but was readmitted to the hospital for nausea, vomiting, and abdominal pain secondary to choledocholithiasis, which resulted in cholangitis. She had a long history of heartburn and had been previously diagnosed with GERD. The day after admission, endoscopic retrograde cholangiopancreatography was attempted; however, the scope could not be passed into the stomach. Instead, an esophagogastroduodenoscopy was performed, which showed severe esophagitis with distal esophageal stricture (Fig. 1A). The stricture was not traversable. After receiving pantoprazole for 5 days (80 mg intravenous bolus, followed by 8 mg/h intravenous infusion for 72 hours, then 40 mg by mouth once a day), a repeat esophagogastroduodenoscopy was performed and demonstrated that the esophagitis completely resolved and the scope traversed the esophagus without difficulty (Fig. 1B). Endoscopic retrograde cholangiopancreatography was subsequently performed and a common bile duct stent was placed successfully.
In review of the literature, we did not identify any studies that showed severe esophagitis healing in less than a week. Although the number of patients we observed is small, we think that this is a very important initial clinical observation. Further randomized, controlled studies are needed to define the precise healing time for severe esophagitis treated with intravenous pantoprazole.
Kila Dabney-Smith, M.D.
Jae Nam, M.D.
Amaar Ghazale, M.D.
Qiang Cai, M.D., Ph.D.
1. Anonymous. Pantoprazole (Protonix). Med Lett Drugs Ther 2000; 42:65–6.
2. Mossner J, Holscher AH, Herz R, et al. A double-blind study of pantoprazole and omeprazole in the treatment of reflux esophagitis: a multicenter trail. Aliment Pharmacol Ther 1995; 9:321–6.
3. Ramirez-Barba EJ, et al. Low-dose pantoprazole (20 mg) is effective in the treatment of mild reflux oesophagitis. Clin Drug Invest 1999; 18:445–51.
4. Metz DC, Pratha V, Martin P, et al. Oral and intravenous dosage forms of pantoprazole are equivalent in their ability to suppress gastric acid secretion in patients with gastroesophageal reflux disease. Am J Gastroenterol 2000; 95:626–33.