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Buffered NAD+ ships with a pH stabilizer (most commonly Tris) that brings the reconstituted solution closer to physiological pH (~7-8.5), while unbuffered NAD+ reconstitutes acidic (~pH 3-4) and is more often associated with injection-site stinging

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Decking UK, Schlieper G, Kroll K, Schrader J: Hypoxia-induced inhibition of adenosine kinase potentiates cardiac adenosine release

Stomach acid is extremely powerful (its used to break down food after all), so this disorder can cause all sorts of long-term problems if silent reflux is chronic and goes untreated