What are the management and treatment options for dyspepsia?

Management and Treatment of Dyspepsia

The management of dyspepsia should follow a structured approach starting with testing for H. pylori in most patients, followed by acid suppression therapy with proton pump inhibitors (PPIs) as first-line treatment, and progressing to neuromodulators like tricyclic antidepressants for refractory cases. 1

Initial Assessment and Diagnosis

Diagnostic Approach

• Age-based evaluation:

  • Patients ≥55 years with dyspepsia or those with alarm symptoms require prompt endoscopy 1
  • Alarm symptoms include weight loss, persistent vomiting, progressive dysphagia, GI bleeding, iron deficiency anemia, or family history of gastro-esophageal cancer 1
  • Consider urgent CT scan in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1

• Laboratory testing:

  • Full blood count in patients ≥55 years
  • Coeliac serology in patients with overlapping IBS-type symptoms 1

• For patients without alarm features:

  • Non-invasive testing for H. pylori ("test and treat" strategy) is recommended as first-line approach 1
  • Confirmation of successful H. pylori eradication is only necessary in patients with increased risk of gastric cancer 1

First-Line Treatment Options

Lifestyle Modifications

• Regular aerobic exercise is strongly recommended for all patients with functional dyspepsia (FD) 1
• Avoid specific food triggers that consistently worsen symptoms
• Consider smaller, more frequent meals
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets 1

Pharmacological Treatment

1. H. pylori positive patients:

   • Eradication therapy is highly effective (strong recommendation, high-quality evidence) 1
   • Monitor for adverse events which are more common than with control therapy

2. H. pylori negative patients or those who remain symptomatic after eradication:

   • Proton pump inhibitors (PPIs) are strongly recommended as first-line therapy 1

     • Use lowest effective dose that controls symptoms
     • Examples: omeprazole 20 mg daily, lansoprazole 30 mg daily
     • PPIs should be taken 30-60 minutes before a meal for optimal effect 2

   • Histamine-2 receptor antagonists may be effective (weak recommendation, low-quality evidence) 1

     • Well-tolerated alternative to PPIs

   • Prokinetic agents may be considered for dysmotility-like symptoms (fullness, bloating, early satiety) 1

     • Efficacy varies by drug class
     • Many effective prokinetics are unavailable outside Asia and USA
     • Caution: Metoclopramide carries significant risk of tardive dyskinesia and should be used short-term with careful monitoring 3

Second-Line Treatment Options

For Patients with Inadequate Response to First-Line Therapy

• Tricyclic antidepressants (TCAs) as gut-brain neuromodulators 1

  • Strong recommendation, moderate-quality evidence
  • Start at low dose (e.g., amitriptyline 10 mg once daily)
  • Titrate slowly to maximum of 30-50 mg once daily
  • Requires careful explanation of rationale to patients
  • Monitor for side effects

• Consider switching therapy approaches:

  • If PPI fails, try prokinetic or vice versa 4
  • For partial response to PPI, consider increasing to twice-daily dosing 1

• Antipsychotics may be considered in select cases 1

  • Sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily
  • Requires careful explanation and monitoring

Management of Severe or Refractory Dyspepsia

• Multidisciplinary approach is strongly recommended 1

  • Team should include gastroenterologists, dietitians, and psychologists
  • Early dietitian involvement to avoid overly restrictive diets

• Important cautions:

  • Avoid opioids and surgery in patients with refractory FD 1
  • Assess for eating disorders in patients with weight loss and food restriction 1
  • Routine gastric emptying testing or 24-hour pH monitoring is not recommended 1

• Psychological interventions may be beneficial but evidence is limited 1, 5

  • These therapies leverage the gut-brain connection

Common Pitfalls to Avoid

1. Failing to test for H. pylori before initiating long-term therapy
2. Continuing ineffective treatments without reassessing diagnosis
3. Using metoclopramide long-term due to risk of tardive dyskinesia 3
4. Overuse of endoscopy in younger patients without alarm features
5. Inadequate explanation of neuromodulator use leading to poor adherence
6. Overly restrictive diets leading to malnutrition or disordered eating

Treatment Algorithm

1. Initial presentation: Assess for alarm features and age ≥55 years

   • If present → Endoscopy
   • If absent → Test for H. pylori

2. H. pylori positive: Provide eradication therapy

   • If symptoms resolve → No further treatment
   • If symptoms persist → Move to acid suppression

3. H. pylori negative or persistent symptoms after eradication:

   • Trial of PPI for 4-8 weeks
   • If symptoms resolve → Stop treatment; restart if symptoms recur
   • If inadequate response → Consider switching to H2 antagonist or prokinetic

4. Persistent symptoms despite first-line treatments:

   • Trial of low-dose TCA (e.g., amitriptyline)
   • Consider referral to gastroenterology specialist

5. Severe or refractory symptoms:

   • Multidisciplinary management
   • Consider psychological therapies
   • Avoid opioids and unnecessary procedures

The management of dyspepsia has evolved significantly, with better understanding of the pathophysiology leading to more targeted treatments. However, many patients will experience fluctuating symptoms requiring ongoing management and adjustment of therapeutic approaches.