What is the treatment approach for anxiety in patients with functional dyspepsia?

Treatment of Anxiety in Functional Dyspepsia

Tricyclic antidepressants (TCAs) are the recommended first-line treatment for anxiety in patients with functional dyspepsia, starting with low-dose amitriptyline 10 mg daily and titrating slowly to 30-50 mg daily as needed. 1

First-Line Approach for Anxiety in Functional Dyspepsia

Pharmacological Management

• Tricyclic Antidepressants (TCAs):
  • Start with amitriptyline 10 mg once daily 1
  • Titrate slowly to a maximum of 30-50 mg once daily based on response 1
  • Provide careful explanation to patients about the rationale for using these medications as gut-brain neuromodulators, not as antidepressants 1
  • Counsel patients about potential side effects (dry mouth, constipation, drowsiness) 1

Non-Pharmacological Approaches

• Regular aerobic exercise is strongly recommended for all FD patients, which can help reduce anxiety symptoms 1, 2
• Dietary modifications:
  • Consume 4-6 small meals throughout the day rather than 3 large ones 2
  • Avoid foods that may trigger symptoms (fatty, spicy, acidic foods) 2
  • Separate liquids from solids during meals 2
  • Ensure adequate hydration (at least 1.5L daily) 2

Second-Line Options for Anxiety in FD

If TCAs are ineffective or not tolerated, consider:

• Antipsychotics such as sulpiride (100 mg four times daily) or levosulpiride (25 mg three times daily) 1, 3

  • Provide careful explanation about their use and counsel patients about side effects
  • Note that levosulpiride has shown potential benefit but conclusive evidence is limited 3

• SSRIs may be considered in specific cases:

  • Evidence for SSRIs in FD is mixed, with some studies showing benefit for anxiety reduction 4, 3
  • However, systematic reviews suggest SSRIs alone may not be effective for FD symptoms 5, 3

Management of Severe or Refractory Cases

For patients with severe anxiety and refractory FD symptoms:

• Multidisciplinary team approach is strongly recommended, including gastroenterologists, psychologists, and dietitians 1
• Metacognitive Therapy (MCT) has demonstrated better efficacy in treating anxiety symptoms compared to nortriptyline in patients with FD 6
• Avoid opioids and surgery as these can worsen outcomes and cause iatrogenic harm 1

Important Clinical Considerations

• Anxiety may contribute to excessive air swallowing and PPI refractoriness in patients with FD 7
• Patients with moderate/severe anxiety show significantly higher FD symptom scores and are more likely to be non-responders to PPI therapy 7
• Up-front evaluation with anxiety questionnaires may help identify patients who need anxiety-focused treatment 7

Monitoring and Follow-up

• Assess response to TCA therapy after 4-6 weeks
• If partial response, consider dose adjustment
• If no response after adequate trial at maximum tolerated dose, switch to second-line therapy
• Monitor for improvement in both anxiety symptoms and FD symptoms

Pitfalls to Avoid

• Dosing errors: Starting TCAs at too high a dose can lead to intolerable side effects and treatment discontinuation
• Inadequate explanation: Failing to explain the gut-brain connection and rationale for using neuromodulators can reduce adherence
• Overlooking anxiety: Not addressing anxiety as a contributor to FD symptoms can lead to treatment failure
• Overreliance on PPIs: Continuing PPI therapy despite evidence of anxiety-driven symptoms and PPI refractoriness 7
• Restrictive diets: Overly restrictive diets can lead to malnutrition or disordered eating 1