Is it safe for a middle-aged adult with a history of nonsteroidal anti-inflammatory drug (NSAID)-induced gastritis, currently experiencing sourness and bloating, to taper off Nexium (esomeprazole) every other day after three weeks of daily 40mg treatment?

Tapering Nexium After NSAID-Induced Gastritis

Your every-other-day tapering approach after 3 weeks of daily 40mg Nexium is reasonable and safe, and the transient nausea you experienced is likely rebound acid hypersecretion (RAHS), which is expected and should be managed with on-demand antacids or H2-blockers rather than immediately resuming daily PPI therapy. 1

Understanding What You're Experiencing

The brief nausea after your first day off Nexium is almost certainly rebound acid hypersecretion (RAHS), not a sign that your gastritis hasn't healed. 1 This occurs because:

• During chronic PPI therapy (even just 3 weeks), your stomach develops compensatory changes—increased parietal cells that produce more acid when the PPI is withdrawn 1
• These symptoms typically occur within the first few days of discontinuation and may persist for 3-7 days, with complete resolution taking 2-6 months as your stomach readjusts 1
• The fact that your nausea resolved quickly and you have no ongoing sourness is reassuring—this is exactly the pattern of transient RAHS 1

Your Tapering Strategy

Both gradual tapering (your current approach) and abrupt discontinuation are acceptable strategies, as clinical trials show no significant difference in success rates between the two (31% vs 22% remaining off PPIs at 6 months). 1 Your every-other-day approach for tapering is a reasonable middle ground.

Managing Breakthrough Symptoms

Do not immediately resume daily Nexium if you experience transient symptoms. Instead: 1

• Use on-demand H2-receptor antagonists (like famotidine/Pepcid) for symptom control 1
• Use over-the-counter antacids (Tums, Maalox) as needed 1
• Consider on-demand PPI use—taking Nexium only when symptoms occur, rather than daily 1

When to Worry

You should only consider resuming continuous PPI therapy if: 1

• Severe persistent symptoms last more than 2 months after discontinuation (yours resolved within hours, so this doesn't apply)
• You develop alarm symptoms: hematemesis (vomiting blood), melena (black tarry stools), significant weight loss, or difficulty swallowing 2

Critical Context for Your Situation

Since you've discontinued NSAIDs (the cause of your gastritis), you have a much lower risk of recurrence compared to patients who must continue NSAIDs. 3, 4

• After 3 weeks of PPI therapy for NSAID-induced gastritis with symptom improvement, most mucosal healing has likely occurred 4
• Your rapid symptom improvement (almost immediate) suggests less severe mucosal damage compared to your summer episode 4
• Maintenance PPI therapy is generally not necessary after NSAID discontinuation unless you have other risk factors 2

Practical Next Steps

1. Continue your every-other-day taper for 1-2 weeks 1
2. Keep famotidine (Pepcid) or antacids on hand for any breakthrough symptoms 1
3. Expect some transient discomfort over the next week—this is normal RAHS, not gastritis recurrence 1
4. After completing the taper, use Nexium only on-demand if symptoms return 1
5. Permanently avoid NSAIDs (ibuprofen, naproxen, aspirin for pain) to prevent recurrence 2, 3

Common Pitfalls to Avoid

• Don't interpret every symptom during tapering as gastritis recurrence—most are temporary RAHS 1
• Don't resume continuous daily PPI therapy at the first sign of discomfort—use on-demand H2-blockers or antacids first 1
• Don't take NSAIDs again without gastroprotection, even for acute pain—use acetaminophen (Tylenol) instead 2, 3

Your anxiety about the nausea is understandable, but the fact that it resolved quickly without ongoing symptoms is exactly what we expect from normal RAHS during PPI withdrawal. You're doing well.