⚠️ Warnings
Hepatic impairment. Patients with severe hepatic impairment should have their liver enzyme levels monitored regularly, especially during long-term treatment. If liver enzyme levels rise, treatment with the medicinal product should be discontinued.
Combination therapy. During combination therapy, the instructions for use of the respective medicinal products should be followed.
Gastric malignancy. Symptomatic response to pantoprazole may mask the symptoms of gastric malignancy and delay its diagnosis. In the presence of alarm symptoms (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis, anaemia, melaena), and when a gastric ulcer is suspected or present, malignancy should be excluded.
If symptoms persist despite adequate treatment, further investigation should be considered.
HIV protease inhibitors. Co-administration of pantoprazole with HIV protease inhibitors (such as atazanavir) whose absorption is pH-dependent is not recommended, due to significant reduction in their bioavailability (see section "Interactions with other medicinal products and other forms of interaction").
Effect on vitamin B₁₂ absorption.
Pantoprazole may reduce the absorption of vitamin B₁₂ (cyanocobalamin) due to hypo- or achlorhydria. This should be taken into consideration in patients with reduced body weight or risk factors for decreased vitamin B₁₂ (cyanocobalamin) absorption, especially during long-term treatment or in the presence of relevant clinical symptoms.
Long-term treatment. During long-term treatment, especially exceeding 1 year, patients should remain under regular medical supervision.
Gastrointestinal infections caused by bacteria.
Treatment with the product may slightly increase the risk of gastrointestinal infections caused by bacteria such as Salmonella and Campylobacter or C. difficile.
Hypomagnesaemia. Rare cases of severe hypomagnesaemia have been reported in patients treated with PPIs such as pantoprazole for at least 3 months, and in most cases for 1 year. The following serious clinical manifestations of hypomagnesaemia may occur and develop insidiously: fatigue, tetany, delirium, convulsions, dizziness, and ventricular arrhythmia. Hypomagnesaemia may lead to hypocalcaemia and/or hypokalaemia (see section "Special warnings and precautions for use"). In cases of hypomagnesaemia (and associated hypocalcaemia and/or hypokalaemia), the condition of most patients improved after magnesium replacement therapy and discontinuation of PPI treatment.
For patients expected to be on prolonged treatment, or patients taking PPIs concomitantly with digoxin or medicinal products that may cause hypomagnesaemia (e.g. diuretics), magnesium levels should be measured before initiating PPI therapy and periodically during treatment.
Bone fractures. Long-term treatment (more than 1 year) with high-dose proton pump inhibitors may moderately increase the risk of hip, wrist, and spine fractures, predominantly in elderly patients or in the presence of other risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be attributable to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and should have adequate intake of vitamin D and calcium.
Severe cutaneous adverse reactions (SCARs).
Severe cutaneous adverse reactions have been reported with pantoprazole, including erythema multiforme, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS syndrome), which may be life-threatening or fatal. The frequency of these reactions is not known (see section "Adverse reactions").
When prescribing pantoprazole, patients should be informed about the signs and symptoms, and skin reactions should be monitored closely. If symptoms suggestive of these severe cutaneous reactions appear, pantoprazole should be discontinued immediately and alternative treatment considered.
Subacute cutaneous lupus erythematosus. The use of proton pump inhibitors has been associated with very rare cases of subacute cutaneous lupus erythematosus. If lesions occur, especially on sun-exposed areas of the skin, and are accompanied by arthralgia, the patient should seek medical attention promptly, and the physician should consider discontinuing Nolpaza®. The occurrence of subacute cutaneous lupus erythematosus with previous PPI therapy may increase the risk of its development with other proton pump inhibitors.
Effect on laboratory test results.
Elevated chromogranin A (CgA) levels may interfere with diagnostic investigations for neuroendocrine tumours. To avoid such interference, Nolpaza® treatment should be temporarily discontinued for at least 5 days before CgA level assessment (see section "Pharmacodynamics"). If CgA and gastrin levels have not returned to the normal range after the initial measurement, repeat measurements should be performed 14 days after discontinuation of PPI treatment.
Information on excipients.
Nolpaza® contains sorbitol. Patients with rare hereditary fructose intolerance should not use this product.