What is the initial treatment for functional dyspepsia?

Initial Treatment for Functional Dyspepsia

For patients with functional dyspepsia, the initial treatment should be non-invasive testing for Helicobacter pylori ('test and treat') followed by empirical acid suppression therapy if H. pylori negative or if symptoms persist after eradication therapy. 1

Diagnostic Approach

Before initiating treatment, functional dyspepsia (FD) should be properly diagnosed:

• FD is diagnosed in the presence of bothersome epigastric pain/burning, early satiation, and/or postprandial fullness lasting >8 weeks, without structural abnormalities 1
• FD can be classified into two subtypes:
  • Postprandial distress syndrome (PDS): early satiation and postprandial fullness
  • Epigastric pain syndrome (EPS): epigastric pain or burning

Initial Investigations

• Full blood count in patients ≥55 years with dyspepsia
• Coeliac serology in patients with overlapping IBS-type symptoms
• Urgent endoscopy only if:
  • Age ≥55 years with weight loss
  • Age >40 years from high gastric cancer risk area or with family history of gastro-oesophageal cancer 1

Treatment Algorithm

First-Line Treatment

1. H. pylori testing and eradication:

   • Offer non-invasive testing (stool antigen or urea breath test) for H. pylori
   • If positive, provide eradication therapy
   • Confirmation of successful eradication only needed in patients at increased risk of gastric cancer 1

2. If H. pylori negative or symptoms persist after eradication:

   • Empirical acid suppression therapy:
     • Proton pump inhibitors (PPIs) at lowest effective dose (strong recommendation, high-quality evidence) 1
     • Histamine-2 receptor antagonists (H2RAs) are an alternative option (weak recommendation, low-quality evidence) 1

3. Lifestyle modifications:

   • Regular aerobic exercise (strong recommendation) 1
   • Avoid trigger foods and consider smaller, more frequent meals 2
   • Minimize coffee intake, smoking, and excess alcohol 2

Second-Line Treatment

If symptoms persist despite first-line treatments:

1. Prokinetic agents (particularly for dysmotility-like symptoms):

   • Metoclopramide (short-term use with discussion of side effects) 2
   • Other prokinetics like acotiamide, itopride, and mosapride may be effective but availability varies by country 1

2. Tricyclic antidepressants (TCAs) as gut-brain neuromodulators:

   • Start at low dose (e.g., amitriptyline 10mg once daily)
   • Titrate slowly to maximum 30-50mg once daily
   • Requires careful explanation of rationale for use 1

Special Considerations

For Refractory Cases

• Multidisciplinary approach involving gastroenterologists, dietitians, and psychologists 1
• Avoid opioids and surgery to minimize iatrogenic harm 1
• Consider psychological therapies like cognitive behavioral therapy 3
• Assess for eating disorders in patients with weight loss and food restriction 1

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure proper distinction between FD and other conditions like gastroesophageal reflux disease or irritable bowel syndrome 2
2. Inadequate explanation: FD should be introduced as a disorder of gut-brain interaction with clear explanation of the gut-brain axis 1
3. Overuse of endoscopy: Reserve for patients meeting specific age and risk criteria 1
4. Overly restrictive diets: Early dietitian involvement to prevent nutritional deficiencies 1
5. Inappropriate use of opioids: These should be avoided in FD management 1

By following this evidence-based approach, most patients with functional dyspepsia can achieve symptom improvement and better quality of life.