Why am I experiencing heartburn, intense hunger after meals, and sourness after stopping esomeprazole (Nexium) 40 mg daily for three weeks for NSAID‑induced gastritis, and what should I do?

Why You're Experiencing Symptoms After Stopping Nexium

You are experiencing rebound acid hypersecretion (RAHS), a completely expected physiologic response that occurs in approximately 50% of patients after stopping PPIs—this does NOT mean you've "redone" your healing or that your gastritis has returned. 1, 2

What's Actually Happening

Your symptoms (acid reflux, soreness, intense hunger after meals) are caused by a temporary overproduction of stomach acid that develops after PPI withdrawal, not a recurrence of your NSAID-induced gastritis. 2 Here's why:

• During your 3 weeks on Nexium 40 mg daily, your stomach compensated for the acid suppression by growing more acid-producing cells (parietal cell hyperplasia). 2
• When you stopped the PPI, these extra cells suddenly became active all at once, creating a surge of acid production beyond your baseline. 2
• This rebound effect typically lasts 3-7 days but can persist for 2-6 months before your stomach fully readjusts. 2

Why Your Dinner Triggered Symptoms

Your pasta with red sauce, meatballs, and bread represents multiple gastric triggers simultaneously:

• Tomato-based red sauce is highly acidic and a well-known GERD trigger, especially problematic during the RAHS period when your stomach is already overproducing acid. 3
• Large meal volume increases intra-abdominal pressure and can trigger reflux, particularly when your lower esophageal sphincter is still recovering. 3
• The combination of stress (your midterm tomorrow) likely increased your visceral hypersensitivity, making you more aware of normal gastric sensations. 3

What You Should Do Right Now

Continue your current tapering schedule and manage breakthrough symptoms with on-demand therapy rather than immediately resuming continuous Nexium. 1, 2, 4

Immediate symptom management:

• Use H2-receptor antagonists (like famotidine/Pepcid) on-demand for breakthrough symptoms—these provide acid suppression without perpetuating the rebound cycle. 2, 4
• Continue using Tums or other antacids as needed for immediate relief. 2, 4
• Take Nexium only when symptoms occur (on-demand dosing) rather than returning to daily use—this is an acceptable partial de-prescribing strategy. 2, 4

Dietary modifications during this transition:

• Avoid meals within 3 hours of bedtime and elevate the head of your bed to reduce supine reflux. 3
• Temporarily avoid high-acid foods (tomato sauce, citrus, vinegar) and large meal volumes until the RAHS period resolves. 3
• Eat smaller, more frequent meals to reduce gastric distension. 3

When to Worry vs. When to Wait

Do NOT resume continuous daily Nexium unless severe persistent symptoms last more than 2 months after discontinuation. 1, 2, 4

This is normal and expected (wait it out):

• Intermittent soreness, acid reflux, or hunger sensations in the first 2-6 months after stopping. 2
• Symptoms triggered by specific foods or stress during this transition period. 2
• Good days alternating with symptomatic days—this fluctuation is typical of RAHS resolution. 2

This requires medical attention:

• Severe persistent symptoms lasting more than 2 months that cannot be controlled with on-demand therapy. 2, 4
• Development of alarm symptoms: difficulty swallowing, unintentional weight loss, persistent vomiting, or evidence of GI bleeding. 3, 5
• Need to take Nexium for more than 14 consecutive days or more than one 14-day course every 4 months. 5

Critical Reassurance

Your 3-week course of Nexium 40 mg was appropriate for NSAID-induced gastritis and has already done its job healing the mucosal damage. 6, 7, 8 The symptoms you're experiencing now are:

1. Not a sign that you've "undone" your healing—the gastritis healed during your PPI course. 7, 8
2. Not an indication to restart continuous daily therapy—approximately 75% of patients who successfully discontinue PPIs use H2-blockers or antacids for symptom control during the transition. 4
3. Expected and temporary—your stomach needs 2-6 months to fully readjust its acid production after chronic PPI therapy. 2

Common Pitfalls to Avoid

• Don't interpret every symptom during the first 2 months as treatment failure—transient symptoms from RAHS do not necessarily mean you need continuous PPI therapy. 2
• Don't resume daily Nexium based on a single bad day or meal—use on-demand dosing instead. 2, 4
• Don't continue avoiding all trigger foods indefinitely—once the RAHS period resolves (2-6 months), you can gradually reintroduce foods. 3

Your stress about the midterm is likely amplifying your symptom perception through the brain-gut axis, making normal gastric sensations feel more intense. 3 The fact that you've had "no symptoms, no bloating" for most of your tapering period is excellent evidence that your gastritis has healed and you're simply experiencing the expected temporary rebound effect. 2, 4