I was diagnosed with NSAID‑induced gastritis 4 weeks ago, took esomeprazole (Nexium) 40 mg daily for 3 weeks, stopped, and now have pain, bloating, and post‑prandial dizziness after a large mixed meal—should I restart a proton‑pump inhibitor and how should I taper it?

Management of Post-PPI Discontinuation Symptoms in NSAID-Induced Gastritis

Direct Recommendation

You should restart esomeprazole 40 mg daily immediately and continue it for at least 8 weeks, then maintain on continuous daily therapy indefinitely rather than attempting to taper off, because NSAID-induced erosive gastritis requires ongoing acid suppression to prevent recurrence. 1

Why Your Symptoms Returned

Your current symptoms—pain, bloating, and post-prandial dizziness after a large mixed meal—represent rebound acid hypersecretion, a physiologic phenomenon where your stomach's increased parietal cell mass unleashes heightened acid production once PPIs are stopped. 2 This is a predictable consequence of discontinuing PPI therapy after only 3 weeks of treatment for NSAID-induced gastritis, which typically requires 4-8 weeks for initial healing. 1, 3

The trigger meal you described (pasta with red sauce, meatballs, bread, and edamame) was particularly problematic because:

• Red/tomato sauce is highly acidic
• Large meal volume increases gastric distension and vagal stimulation
• High fat content from meatballs delays gastric emptying

Correct Treatment Duration for NSAID-Induced Gastritis

You stopped your PPI too early. The evidence is clear:

• Initial healing phase: 4-8 weeks of daily PPI therapy is required for healing erosive gastritis 1, 3
• Maintenance phase: Patients with documented erosive gastritis (which NSAID-induced gastritis typically is) require continuous daily PPI therapy indefinitely to prevent recurrence 1
• On-demand or intermittent therapy is explicitly contraindicated for erosive gastritis—this approach only works for non-erosive reflux disease and leads to unacceptably high recurrence rates 1, 3

Your 3-week course was insufficient, and attempting to taper off was inappropriate for this diagnosis.

Specific Treatment Plan

Immediate Actions (Next 8 Weeks)

1. Restart esomeprazole 40 mg once daily, taken 30-60 minutes before your first meal of the day 1, 3

   • Timing is critical—PPIs must be taken before meals to coincide with postprandial peak in active proton pumps 3
   • Continue for a full 8 weeks minimum 1

2. Discontinue NSAIDs completely if at all possible, as they are gastric mucosal irritants 1

   • If pain control is needed, switch to acetaminophen 1
   • If NSAIDs are absolutely necessary, you will need prophylactic PPI therapy indefinitely 4

3. Test for H. pylori infection if not already done 4

   • H. pylori eradication reduces NSAID-associated ulcer risk in NSAID-naïve users 4
   • Use 13C urea breath test or stool antigen test (not serology) 4

Long-Term Maintenance Strategy

After 8 weeks of healing, you need continuous daily PPI therapy—not tapering, not on-demand dosing. 1 This is the fundamental error in your current approach. The guidelines are unequivocal:

• Daily maintenance dosing is essential for erosive gastritis 1
• Recurrence rates are unacceptably high with less-than-daily dosing 1
• This is analogous to Los Angeles grade B erosive esophagitis, which requires indefinite daily therapy 1

Dietary Modifications During Treatment

Implement these changes immediately:

• Avoid trigger foods: tomato-based sauces, citrus, chocolate, caffeine, alcohol, spicy foods 1
• Limit dietary fat to less than 45 grams per day 1
• Avoid recumbency for 2-3 hours after meals 1
• Smaller, more frequent meals rather than large volume meals that caused your current symptoms 1

Critical Pitfalls You Must Avoid

1. Never attempt tapering or on-demand PPI therapy for documented NSAID-induced gastritis—this is only appropriate for functional dyspepsia, not erosive disease 1, 3

2. Do not substitute H2-receptor antagonists (like ranitidine or famotidine) for PPI maintenance—they are significantly less effective, with patients up to twice as likely to have recurrent disease 1, 5

3. Do not assume symptom improvement means you can stop therapy—erosive gastritis requires continuous suppression regardless of symptoms 1

4. Do not resume NSAIDs without prophylactic PPI therapy—if you must use NSAIDs chronically, you need continuous PPI co-therapy 4

When to Consider Endoscopy

You should undergo endoscopy if:

• Symptoms persist despite 4-8 weeks of twice-daily PPI therapy 3
• You develop alarm symptoms: dysphagia, bleeding, anemia, weight loss, or recurrent vomiting 4, 3
• You are over age 45-50 (depending on local gastric cancer incidence) with new-onset symptoms 4

Special Consideration: If You Must Continue NSAIDs

If you have a compelling indication for chronic NSAID therapy (e.g., rheumatoid arthritis), the appropriate strategy is:

• NSAID + PPI combination therapy is rated as "appropriate" for patients with previous GI events 4
• Consider switching to a COX-2 selective inhibitor (celecoxib) plus PPI for highest-risk patients 4
• Never use NSAID alone after documented NSAID-induced gastritis 4

Bottom Line

Your attempt to taper off esomeprazole after 3 weeks was premature and inappropriate for NSAID-induced gastritis. Restart esomeprazole 40 mg daily immediately, continue for at least 8 weeks, then maintain on continuous daily therapy indefinitely. 1 This is not optional—it is the standard of care for erosive gastritis, and attempting to discontinue or taper will result in recurrent symptoms and potential complications. 1, 3