I had Helicobacter pylori infection last year, successfully treated with quadruple therapy and a negative stool test; can I taper dexlansoprazole (Dexilant) to 30 mg every other day with famotidine (Pepcid) on the off days?

Tapering Dexilant After Successful H. pylori Eradication

Yes, you can safely taper dexlansoprazole to 30 mg every other day with famotidine on off days after successful H. pylori eradication, provided you have no ongoing indication for continuous PPI therapy. 1

Your Clinical Context

• You have successfully eradicated H. pylori (confirmed by negative stool test), which means the underlying cause of your acid-related symptoms has been eliminated. 2, 3
• H. pylori eradication cures chronic gastritis and eliminates the need for long-term acid suppression in most patients without complicated disease. 2, 3
• Without a definitive ongoing indication (such as severe erosive esophagitis, Barrett's esophagus, or high GI bleeding risk), you are an ideal candidate for PPI de-prescribing. 1

Evidence-Based Tapering Strategy

Either Tapering or Abrupt Discontinuation Is Acceptable

• The 2022 AGA guidelines state that either dose tapering or abrupt discontinuation can be considered when de-prescribing PPIs, as a trial comparing the two approaches showed no significant difference in remaining off PPIs at 6 months (31% vs 22%). 1
• Your proposed taper (30 mg every other day with famotidine on off days) is a reasonable middle-ground approach that gradually reduces acid suppression while providing symptom control. 1

Managing Rebound Acid Hypersecretion (RAHS)

• You should expect transient upper GI symptoms (heartburn, regurgitation) for up to 2-8 weeks after reducing or stopping PPIs due to rebound acid hypersecretion. 1
• Using famotidine (an H2-receptor antagonist) on off days is explicitly recommended by the AGA as a strategy to manage breakthrough symptoms during PPI withdrawal. 1
• Three-quarters of patients who successfully discontinued PPIs were using H2-receptor antagonists or antacids for symptom control at 6 months. 1
• Symptoms lasting more than 2 months after PPI discontinuation may suggest a continuing indication for PPI therapy and warrant re-evaluation. 1

Practical Implementation

Step-by-Step Approach

1. Begin your taper: Dexilant 30 mg every other day with famotidine 20-40 mg on alternate days. 1
2. Continue this schedule for 2-4 weeks to allow your stomach to adjust. 1
3. If symptoms are well-controlled, further reduce to famotidine as-needed only. 1
4. If severe persistent symptoms develop (lasting >2 months), consider returning to daily PPI and discussing with your physician. 1

On-Demand Therapy Option

• Using PPIs "on-demand" (only when symptomatic) provides effective symptom control and is an acceptable partial de-prescribing strategy. 1
• This approach allows you to take dexlansoprazole only when needed rather than on a fixed schedule. 1

Critical Considerations

When NOT to Taper

• Do not attempt de-prescribing if you have: 1
  • History of severe erosive esophagitis (Los Angeles grade C or D)
  • Barrett's esophagus
  • Peptic stricture
  • High risk for upper GI bleeding (e.g., dual antiplatelet therapy, anticoagulation)

Why De-Prescribing Is Appropriate

• The decision to discontinue PPIs should be based solely on lack of indication, not fear of side effects. 1
• After successful H. pylori eradication, most patients with uncomplicated gastritis or duodenal ulcer do not require long-term PPI therapy. 1, 2, 3
• PPIs are generally safe, but patients should not use any medication when there is no reasonable expectation of benefit. 1

Common Pitfalls to Avoid

• Do not interpret early rebound symptoms (first 2-8 weeks) as treatment failure—this is expected RAHS and does not mean you need continuous PPIs. 1
• Do not stop famotidine abruptly if it is controlling your symptoms—continue as-needed until symptoms resolve. 1
• Do not resume full-dose daily PPI at the first sign of mild heartburn—try on-demand dosing or H2-blockers first. 1

Follow-Up

• Monitor your symptoms over the next 2-6 months as parietal cell hyperplasia regresses. 1
• If you remain symptom-free or well-controlled on as-needed therapy, you have successfully de-prescribed. 1
• If severe symptoms persist beyond 2 months, consult your physician to reassess for other causes (non-acid-mediated symptoms, functional heartburn). 1