Pantoprazole 40 MG Inj (Protonix)

Pantoprazole 40 MG Inj (Protonix)

Non-Formulary Use Criteria: **1. Patient does NOT have Non-Ulcer Dyspepsia: NO APPROVALS. REFER TO COMMISSARY FOR OTC AGENTS***2. GERD: supported by current EGD documentation** **3. Documented doses of ranitidine 750 mg per day divided into qid dosing**4. Documentation of chronic need for NSAIDS with prior history of GI bleed***5. Documented Zollinger-Ellison Syndrome** 6. BID dosing – GERD via ambulatory pH monitoring or upper endoscopy results** 7. Documented Schatzki’s Ring***8. Documented Barrett’s Esophagus**9. Documented Esophageal Stricture** Medical Referral Center (MRC) Use Only**

Dr. M Blatstein

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