In a patient who has cleared Helicobacter pylori and has no high‑risk gastrointestinal disease, what is the best way to taper dexlansoprazole (Dexilant) 30 mg—every other day with famotidine (Pepcid) on off days or abrupt discontinuation and switch to famotidine?

Tapering Dexlansoprazole After H. pylori Eradication

Either abrupt discontinuation or every-other-day tapering are both acceptable strategies for stopping dexlansoprazole 30 mg, with famotidine used as needed for breakthrough symptoms rather than on a scheduled alternating basis. 1

Evidence for Discontinuation Method

The 2022 American Gastroenterological Association guidelines explicitly state that when de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered, with no clear superiority of one method over the other. 1

A randomized trial comparing these approaches found no significant difference in success rates at 6 months:

• Abrupt discontinuation: 31% remained off PPIs symptom-free 1
• Tapered regimen (every-other-day for 3 weeks): 22% remained off PPIs symptom-free 1

The lack of benefit from tapering may be because the 3-week taper was too rapid—parietal cell hyperplasia can take 2-6 months to fully regress. 1, 2

Recommended Approach

For your specific situation after H. pylori clearance:

1. Choose either method based on patient preference:

   • Abrupt cessation: Stop dexlansoprazole 30 mg immediately 1, 2
   • Tapering option: Switch to every-other-day dosing for 3 weeks, then discontinue 1, 2

2. Use famotidine (Pepcid) as needed for breakthrough symptoms only—not on a scheduled alternating basis. 1, 2 Approximately 75% of patients who successfully discontinue PPIs continue using H2-receptor antagonists or antacids for occasional symptom control. 1, 2

Managing Rebound Acid Hypersecretion

Warn the patient about transient upper GI symptoms due to rebound acid hypersecretion (RAHS), which is common after stopping long-term PPI therapy. 1, 3, 2

• Symptoms may persist for up to 8 weeks while parietal cell mass regresses (typically by 6 months) 2
• These symptoms do NOT automatically mean the patient needs to resume continuous PPI therapy 1, 2

For symptom control during this period, use any of these as-needed strategies:

• Famotidine (H2-receptor antagonist) 1, 2
• Over-the-counter antacids 1, 2
• On-demand PPI dosing (only when symptomatic) 1, 2

Follow-Up Timeline

• Reassess at 4-8 weeks after discontinuation to evaluate symptom trajectory 2
• If severe symptoms persist beyond 2 months, consider that a true ongoing indication for PPI therapy may exist or investigate non-acid-mediated causes 1, 2

Why This Patient Is Appropriate for Discontinuation

Since H. pylori has been cleared and there is no mention of high-risk features, this patient meets criteria for de-prescribing. 1, 3 Patients should NOT continue PPIs after H. pylori eradication unless they have:

• Severe erosive esophagitis (LA grade C/D) 1, 3
• Barrett's esophagus 1, 3
• High risk for upper GI bleeding (ongoing NSAIDs/anticoagulants/antiplatelets) 1, 3

Key Pitfall to Avoid

Do not use famotidine on a scheduled alternating-day basis with dexlansoprazole. Instead, stop the PPI (either abruptly or with taper) and use famotidine only as needed for breakthrough symptoms. 1, 2 The scheduled alternating approach has no evidence base and unnecessarily prolongs acid suppression.