Pan vs Pan-D: What's the Difference?

Mechanism in Brief

• Increased esophageal peristaltic amplitude
• Increased lower esophageal sphincter (LES) pressure
• Enhanced gastric emptying
• Antiemetic action via D2 blockade at the chemoreceptor trigger zone (CTZ) - which is outside the BBB, so it works without the CNS side effects of metoclopramide. - Katzung's Basic and Clinical Pharmacology, 16th Ed.

When to Give Which?

Give Pan (Pantoprazole alone) when:

• Simple acid-peptic disease: gastric ulcer, duodenal ulcer, erosive esophagitis
• GERD without significant nausea/vomiting or motility issues
• H. pylori eradication regimens (triple/quadruple therapy)
• Stress ulcer prophylaxis (ICU patients - IV pantoprazole)
• Zollinger-Ellison syndrome (hypersecretory state)
• Upper GI bleed - IV pantoprazole 80 mg bolus is standard
• Patients on NSAIDs/aspirin as gastroprotection
• Long-term maintenance where combination adds no benefit (pantoprazole monotherapy is more cost-effective in GERD than the combination)

Give Pan-D (Pantoprazole + Domperidone) when:

• GERD with nausea, vomiting, or regurgitation - the prokinetic component helps clear esophageal contents and strengthens LES tone, addressing symptoms that PPI alone doesn't fix
• Functional dyspepsia - especially with early satiety, bloating, post-prandial fullness (dysmotility-like symptoms)
• Gastroparesis (diabetic, post-surgical) - domperidone improves gastric emptying
• GERD with delayed gastric emptying - slow emptying worsens reflux; prokinetic breaks this cycle
• Refractory heartburn with persistent regurgitation - when PPI alone hasn't controlled symptoms, adding a prokinetic is the next step - Katzung's, 16th Ed.
• Nausea/vomiting associated with dyspepsia or GERD
• Drug-induced gastroparesis (e.g., opioid use)
• As an adjuvant during antibiotic therapy that causes GI upset

Key Points to Remember

• Dosing timing: Both should be taken 30 minutes before meals - this is especially important for domperidone to maximize prokinetic effect at meal time - Yamada's Textbook of Gastroenterology.
• Domperidone safety: Unlike metoclopramide, domperidone does not cause extrapyramidal effects or tardive dyskinesia because it does not cross the BBB. However, it can prolong the QT interval - avoid in patients with cardiac arrhythmias or on other QT-prolonging drugs.
• Prolactin elevation: Both domperidone and metoclopramide raise prolactin - can cause galactorrhea, gynecomastia, menstrual irregularities.
• Avoid Pan-D long-term without clear indication - the combination adds cost and the domperidone's QT risk accumulates with prolonged use.
• Pan-D is not indicated in erosive esophagitis or ulcer healing - PPI alone is sufficient and preferred.

1. Metro 400 mg (Metronidazole 400 mg)

Uses / When to Give:

2. Inj. Buscopan (Hyoscine Butylbromide 20 mg/mL)

Uses / When to Give (Injection form):

• IV must be given slowly - rapid IV can cause marked hypotension/shock

3. Emecet (Ondansetron)

Uses / When to Give:

• Sublingual form available - useful when patient can't swallow

Quick Summary Table

Acton-OR Tablet

Why This Combination?

Uses / When Is It Given?

Dosing

• Usually once daily, 30 minutes before breakfast
• Short-term use (2-4 weeks) for most indications

Key Points

• Ondansetron vs Domperidone - The "OR" combination (with ondansetron) is preferred when nausea/vomiting is prominent but there is no motility issue (no gastroparesis, no bloating, no regurgitation). If motility is the problem → use Pan-D (domperidone-based)
• Ondansetron does NOT improve gastric emptying - it only stops nausea centrally. So for gastroparesis or bloating, Pan-D is better.
• QT prolongation - both ondansetron and some PPIs can prolong QT slightly; avoid in patients with cardiac arrhythmias or on other QT-prolonging drugs
• Rabeprazole has faster onset than omeprazole/pantoprazole - useful when quick acid relief is needed

Pan-D vs Acton-OR: Quick Comparison