I was treated for ibuprofen‑induced gastritis with pantoprazole 40 mg daily, tapered to 40 mg every other day then to 20 mg every other day, and now have severe dizziness after meals; should I resume 40 mg daily and how should I safely taper?

Managing Post-Meal Dizziness After Pantoprazole Taper for Ibuprofen-Induced Gastritis

Resume pantoprazole 40 mg daily for at least 4 more weeks, then taper more gradually using a slower schedule (40 mg daily → 40 mg every other day for 2-4 weeks → 20 mg daily for 2-4 weeks → 20 mg every other day → discontinue), while recognizing that your post-meal dizziness is unlikely to be gastritis recurrence and requires separate evaluation. 1, 2

Why Your Current Symptoms Are Probably Not Gastritis

Your symptom pattern strongly suggests this is not gastritis returning:

• Classic gastritis symptoms (bloating, soreness, tenderness) have not returned, which would be expected if your gastritis was relapsing 1
• Isolated post-meal dizziness is not a typical gastritis symptom—gastritis causes epigastric pain, bloating, and nausea, not dizziness 1
• The timing (immediate dizziness after just two bites of yogurt) suggests a postprandial hypotension, vasovagal response, or vestibular issue rather than acid-related pathology 1

The Correct Tapering Strategy for Your Situation

Your initial taper was too aggressive. The evidence supports a more gradual approach:

Recommended tapering schedule:

• Week 1-4: Pantoprazole 40 mg daily (re-establish control) 1
• Week 5-8: Pantoprazole 40 mg every other day 1, 2
• Week 9-12: Pantoprazole 20 mg daily 1, 2
• Week 13-16: Pantoprazole 20 mg every other day 1, 2
• After Week 16: Discontinue, using on-demand H2-receptor antagonists (famotidine) or antacids for any breakthrough symptoms 2, 3

The 2022 AGA guidelines confirm that both gradual tapering and abrupt discontinuation are acceptable, but given your symptom recurrence with faster tapering, the slower approach is more appropriate for you 1, 2

Managing Rebound Acid Hypersecretion (RAHS)

When you do stop pantoprazole, expect transient upper GI symptoms:

• RAHS occurs because chronic PPI use causes compensatory parietal cell hyperplasia that takes 2-6 months to regress after stopping 2
• Symptoms typically appear within the first few days and may persist for 3-7 days, with complete resolution taking 2-6 months 2
• Management strategy: Use on-demand H2-receptor antagonists (famotidine 20-40 mg) or over-the-counter antacids rather than immediately resuming continuous PPI therapy 2, 3

Critical Action: Evaluate the Dizziness Separately

You need to address the post-meal dizziness as a distinct problem:

• Check orthostatic vital signs before and after meals to rule out postprandial hypotension 1
• Consider blood glucose monitoring if you have diabetes risk factors (reactive hypoglycemia can cause post-meal dizziness) 1
• Evaluate for vestibular disorders if dizziness persists despite gastric symptom resolution 1
• Review all medications for drug-induced dizziness 1

Common Pitfalls to Avoid

• Do not assume all symptoms during PPI taper are gastritis recurrence—your lack of typical gastric symptoms (pain, bloating, tenderness) argues against this 1
• Do not taper too quickly—jumping from 40 mg every other day to 20 mg every other day was too aggressive; you skipped the intermediate step of 20 mg daily 1, 2
• Do not confuse RAHS symptoms with disease recurrence—RAHS causes heartburn and acid regurgitation, not isolated dizziness 2
• Do not stay on PPIs indefinitely without reassessing—once you complete an adequate treatment course (8-12 weeks total for ibuprofen-induced gastritis), attempt discontinuation with the understanding that most patients do not require chronic therapy for NSAID-induced gastritis after the offending agent is stopped 1

When to Resume Full-Dose PPI

You should return to pantoprazole 40 mg daily if you develop:

• Epigastric pain or burning that is persistent and meal-related 1
• Bloating and tenderness similar to your original presentation 1
• Hematemesis, melena, or severe dysphagia (alarm symptoms requiring immediate endoscopy) 1

Not for isolated dizziness, which requires a different diagnostic approach 1