I am an adult with NSAID‑induced gastritis who was treated with esomeprazole (Nexium) 40 mg daily for four weeks, then tapered to 40 mg every other day and 20 mg daily, but now have persistent post‑prandial dizziness, early hunger, bloating, nausea and a sour taste. What is the best approach to manage these symptoms and safely taper the proton‑pump inhibitor?

Managing PPI Taper and Persistent Symptoms in NSAID-Induced Gastritis

You are experiencing rebound acid hypersecretion (RAHS) from tapering esomeprazole too quickly, and you should return to esomeprazole 20 mg daily for at least 8 weeks to stabilize your symptoms, then attempt a much slower taper using on-demand H2-receptor antagonists (like famotidine) or antacids to manage breakthrough symptoms rather than immediately resuming continuous PPI therapy. 1

Understanding What's Happening to You

Your symptoms—post-meal dizziness, early hunger, bloating, nausea, and sourness—are classic manifestations of RAHS, which occurs because chronic PPI therapy causes compensatory hyperplasia of parietal cells and enterochromaffin-like cells in your stomach. 1 When you dropped from 40 mg to 20 mg daily, you released the increased acid-producing capacity that had built up during your treatment, causing a deep decrease in gastric pH. 1

The key insight: These symptoms don't necessarily mean your gastritis has returned—they often represent temporary RAHS rather than disease recurrence. 1 However, the timeline matters for distinguishing between the two.

Your Immediate Action Plan

Step 1: Stabilize on Current Dose

• Continue esomeprazole 20 mg once daily for a full 8 weeks minimum before attempting any further taper. 2 Your original 4-week course was adequate for initial healing, but you need a longer stabilization period at the lower dose before discontinuing.
• Take your dose before breakfast rather than before dinner or at bedtime, as morning dosing provides superior 24-hour and daytime acid inhibition. 3

Step 2: Manage Breakthrough Symptoms Without Escalating PPI Dose

• Use on-demand H2-receptor antagonists (famotidine) or over-the-counter antacids for your post-meal dizziness, nausea, and sourness rather than increasing your esomeprazole dose back to 40 mg. 1, 4
• DGL (deglycyrrhizinated licorice) can continue as you've found it helpful, but pair it with famotidine for more reliable acid control during this transition period. 1

Step 3: Dietary and Timing Modifications

• Your observation about avoiding eating right before sleep or immediately upon waking is correct—continue this practice as it reduces vagal stimulation and acid reflux episodes.
• The rapid hunger signals you're experiencing (feeling hungry an hour after substantial meals) are likely related to altered gastric emptying and acid rebound, not true hunger. 1 Small, frequent meals may help more than large meals during this stabilization phase.

Timeline Expectations and Red Flags

Normal RAHS Timeline

• Transient upper GI symptoms from RAHS typically occur within the first few days and may persist for 3-7 days, with complete resolution taking 2-6 months. 1
• Your symptoms waxing and waning ("doing great" some days, then "doing bad" others) is entirely consistent with RAHS rather than active gastritis recurrence.

When to Worry

• If severe persistent symptoms last more than 2 months after you eventually discontinue the PPI entirely, this suggests either a continuing indication for PPI therapy or a non-acid-mediated cause requiring further evaluation. 1, 4
• Alarm features requiring immediate medical attention: new difficulty swallowing, persistent vomiting, unintentional weight loss, evidence of GI bleeding, or severe unrelenting pain. 5

Your Eventual Taper Strategy (After 8-Week Stabilization)

When you're ready to taper after 8 weeks of stable symptoms on 20 mg daily:

Option 1: Gradual Dose Reduction (Recommended for You)

• Move to esomeprazole 20 mg every other day for 3 weeks, using famotidine 20 mg on the "off" days. 1
• Then stop esomeprazole entirely and use famotidine or antacids on-demand only when symptoms occur. 1

Option 2: Abrupt Discontinuation

• Clinical trials show no significant difference in success rates between gradual tapering (31%) versus abrupt discontinuation (22%) at 6 months, but given your previous difficulty with the 40→20 mg drop, gradual tapering is more appropriate for you. 1

Why Your Previous Taper Failed

You went from 40 mg daily → 40 mg every other day (successful) → 20 mg daily (failed). This represented too large a reduction in acid suppression too quickly. 1 The every-other-day step at 40 mg was good, but you needed to stay there longer (at least 3-4 weeks) before dropping to 20 mg daily. 1

Common Pitfalls to Avoid

• Don't immediately resume 40 mg daily when you have bad symptom days—this perpetuates the cycle and makes eventual discontinuation harder. 1 Use on-demand H2-blockers instead.
• Don't assume every symptom flare means your gastritis has returned—RAHS symptoms can mimic gastritis but are self-limited if you don't keep escalating PPI doses. 1
• Don't continue eating patterns that trigger symptoms (late-night eating, eating immediately upon waking)—these mechanical factors matter independent of acid suppression.

Long-Term Perspective

Since your gastritis was NSAID-induced (not chronic GERD or H. pylori-related), you have a good chance of successfully discontinuing PPI therapy entirely once your stomach has fully healed and the RAHS period has passed. 1, 4 Most patients with NSAID-induced gastritis don't require indefinite PPI therapy, unlike those with chronic GERD. 4

Your goal is achievable, but requires patience with the timeline—8 weeks of stabilization at 20 mg daily, then a very gradual taper with on-demand acid suppression for breakthrough symptoms. 1