Acute allergic interstitial nephritis after use of pantoprazole

Dear editor, we have gone through the article of Jeffery Ricketson et al related to pantoprozol induced interstitial nephritis. The authors have attributed the episode of interstitial nephritis to pantoprozol, ibuprofen and aspirin and concluded the pantoprozol as the culprit. It is well known that the commonest cause of interstitial nephritis is drugs and nonsteroidal anti-inflammatory drugs and antibiotics top the list.Patient has received all the three drugs for a reasonable period of time and if pantoprozol was the only drug responsible was it dose dependent that it manifested 6 weeks later. Blaming this drug for increase in cardiac events in patients of diabetes mellitus on clopidogrel and pantoprozol and ignoring the underlying disease and clopidogrel resistance(1,2 ) and genetic variability to clopidogrel metabolism. sounds beyond logic as is pantoprozol induced interstitial nephritis .No mention has been made of atorvastatin which is known to cause muscle damage and may have deleterious effect on kidneys as well.Reversiblity of interstitial nephritis is well known on with-holding the culprit drug and it is not clear whether it was ibuprofen or pantoprozol. Gastroenterologists and those who manage the ulcer disease and active bleed with intravenous formulation of pantoprozol will be concerned especially in those parts of the world where endoscopic therapy is unavailable or unaffordable. This will raise questions in intensive care settings where intravenous pantoprozol is routinely used.Few case reports as a support to hypothesis for a lifesaving drug like pantoprozol(most common available intravenous formulation of proton pump inhibitors) is a great concern for practioners.Also authors have not made any comment about the formulation of pantoprozol and actual drug content as the case described has findings of esophagitis and ulcer on endoscopy despite 6 weeks regular use of pantoprozol .Starting a patient on rantidine instead of alternative proton-pump inhibitor is also worth mention as patient is on regular aspirin and latter is likely to worsen any ulcer and retard healing. Have the authors also "followed the direction of wind" and put blame on pantoprozol. COAUTHORS: 1.Dr Waleed Mohd Hussain;2.Dr Mohamed I Fatani; 3.Dr. Loui Ahdal 1.Cytochrome P-450 Polymorphisms and Response to Clopidogrel J. L. Mega and Others .NEJM.Volume 360 — January 22, 2009 — Number 4. Abstract | Full Text | PDF | Supplementary Material 2.Genetic Determinants of Response to Clopidogrel and Cardiovascular Events T. Simon and Others.NEJM Volume 360 — January 22, 2009 — Number 4 3.P. Michael Ho, MD, PhD; Thomas M. Maddox, MD, MSc; Li Wang, MS; Stephan D. Fihn, MD, MPH; Robert L. Jesse, MD, PhD; Eric D. Peterson, MD, MPH; John S. Rumsfeld, MD, PhD . . Risk of Adverse Outcomes Associated With Concomitant Use of Clopidogrel and Proton Pump Inhibitors Following Acute Coronary Syndrome.JAMA. 2009;301(9):937-944. 4. David A. Johnson, MD, FACG, FASGE, FACP, talks about the controversies surrounding the use of clopidogrel (Plavix) and PPIs and suggests clinicians look closely at the data about benefits and risks.

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