I have NSAID‑induced gastritis treated with esomeprazole (Nexium) 40 mg daily for 4 weeks, tapered to 40 mg every other day then 20 mg daily, and now I have persistent post‑prandial dizziness and early hunger—what is the appropriate management?

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

You should return to esomeprazole 40 mg daily for 2-4 weeks to re-establish symptom control, then taper more gradually using 40 mg every other day for at least 2-4 weeks before attempting the step down to 20 mg daily. 1, 2

Understanding Your Current Situation

Your post-prandial dizziness and early hunger are likely manifestations of rebound acid hypersecretion (RAHS), which occurs when you drop your PPI dose too quickly after chronic use. 1 The mechanism involves hypergastrinemia-induced parietal cell proliferation during your initial high-dose PPI therapy, causing excessive acid production when the drug level drops. 1

Why Your Initial Taper Failed

• The jump from 40 mg every other day to 20 mg daily represented too steep a reduction in acid suppression—this effectively halved your average daily dose too abruptly. 1, 2
• Your symptoms improved immediately on 40 mg daily and remained controlled on 40 mg every other day, indicating you needed more gradual dose reduction. 2, 3
• The dizziness you experienced is consistent with vagus nerve stimulation from gastric acid exposure, which you had during your initial presentation. 4

Recommended Tapering Algorithm

Step 1: Re-establish Control (Weeks 1-4)

• Return to esomeprazole 40 mg once daily taken 30-60 minutes before breakfast to fully suppress acid production and eliminate rebound symptoms. 2
• Continue this dose until you have zero post-prandial dizziness for at least 2 consecutive weeks. 2, 5

Step 2: First Taper Phase (Weeks 5-8)

• Switch to esomeprazole 40 mg every other day (alternating with no medication). 1, 2
• Maintain this schedule for a minimum of 4 weeks—longer than your previous attempt—to allow gastrin levels to normalize. 1, 3
• If symptoms recur, return to daily 40 mg for another 2 weeks before re-attempting. 2

Step 3: Second Taper Phase (Weeks 9-12)

• Transition to esomeprazole 20 mg daily only after completing 4 symptom-free weeks on the every-other-day regimen. 1, 2
• Take 20 mg 30-60 minutes before breakfast. 2
• Monitor for 4 weeks at this dose. 2, 3

Step 4: Final Taper (Weeks 13-16)

• Switch to esomeprazole 20 mg every other day for 4 weeks. 1, 2
• If tolerated, attempt complete discontinuation. 1, 2

Addressing Your Specific Symptoms

Post-Prandial Dizziness

• This symptom strongly suggests inadequate acid suppression with vagal stimulation—the same mechanism as your initial presentation. 4
• The dizziness should resolve within 3-5 days of returning to adequate PPI dosing. 4, 5
• Taking your PPI at bedtime instead of before meals reduces efficacy by 40-50%—ensure you take it 30-60 minutes before breakfast. 2

Early Hunger/Rapid Gastric Emptying

• This likely reflects rebound hypergastrinemia causing increased gastric acid secretion and altered gastric motility. 1
• The sensation should normalize as acid suppression is re-established. 1, 3
• This is not true hunger but acid-related discomfort that your brain interprets as hunger. 1

Critical Pitfalls to Avoid

• Never taper faster than 4-week intervals between dose reductions after chronic PPI use—your initial 4-week taper was too aggressive. 1, 2
• Do not take esomeprazole at bedtime—this reduces efficacy because PPIs require active acid secretion (which occurs with meals) to work. 2
• Avoid NSAIDs completely during and for 8 weeks after completing your taper, as your gastric mucosa remains vulnerable. 4
• Do not use H2-receptor antagonists (like famotidine) for breakthrough symptoms during taper—this can worsen rebound by further stimulating gastrin release. 1

When to Seek Re-evaluation

• If symptoms persist despite 8 weeks of esomeprazole 40 mg daily, you need upper endoscopy to rule out alternative diagnoses such as peptic ulcer disease or delayed gastric emptying. 2, 5
• If you develop new symptoms (melena, hematemesis, severe epigastric pain, unintentional weight loss), seek immediate evaluation. 4, 2

Long-Term Considerations

• Most patients with uncomplicated NSAID-induced gastritis can successfully discontinue PPIs using gradual tapering over 12-16 weeks. 1, 2
• If you require NSAIDs again in the future, use the lowest effective dose with concurrent PPI prophylaxis from day one. 4
• Your ability to eat normally (like your quiche) while experiencing dizziness suggests functional symptoms from rebound rather than structural damage—a favorable prognostic sign. 4, 1