What is the treatment for functional dyspepsia eradication?

Treatment of Functional Dyspepsia

For functional dyspepsia eradication, the most effective approach is to test for Helicobacter pylori infection and provide eradication therapy for those who test positive, followed by symptom-based treatment for residual or H. pylori-negative cases. 1

Diagnostic Approach

1. Initial evaluation:

   • Rule out alarm symptoms requiring urgent investigation:
     • Age ≥55 years with treatment-resistant symptoms
     • Raised platelet count
     • Nausea or vomiting
     • Abdominal pain with weight loss in patients ≥60 years (requires urgent CT to exclude pancreatic cancer) 1

2. Testing strategy:

   • Non-invasive H. pylori testing ("test and treat") for patients without alarm features 1
   • Recommended tests: 13C urea breath test, stool test, or validated serological test (sensitivity/specificity ≥90%) 1
   • Confirmation of successful eradication is only necessary in patients with increased risk of gastric cancer 1

Treatment Algorithm

First-line Treatment:

1. For H. pylori-positive patients:

   • Eradication therapy (strong recommendation, high-quality evidence) 1
   • Triple therapy regimen: Amoxicillin 1g twice daily + clarithromycin 500mg twice daily + lansoprazole 30mg twice daily for 14 days (92% eradication rate) 2
   • Alternative dual therapy: Amoxicillin 1g three times daily + lansoprazole 30mg three times daily for 14 days (77% eradication rate) 2

2. For H. pylori-negative patients or those with persistent symptoms after eradication:

   • Symptom-based approach:

     • For epigastric pain/ulcer-like symptoms: Proton pump inhibitors (PPIs) (strong recommendation, high-quality evidence) 1

       • Full dose PPI (e.g., omeprazole 20mg once daily) 1
       • Use lowest effective dose as there is no dose-response relationship 1

     • For fullness, bloating, or early satiety (dysmotility-like symptoms): Prokinetic agents 1

       • Options include acotiamide, itopride, mosapride, or tegaserod (availability varies by region) 1

Second-line Treatment:

1. Tricyclic antidepressants (TCAs) as gut-brain neuromodulators (strong recommendation, moderate-quality evidence) 1

   • Start with amitriptyline 10mg once daily
   • Titrate slowly to 30-50mg once daily as needed
   • Requires careful explanation about rationale (not being used as antidepressants)
   • Common side effects: dry mouth, constipation, drowsiness 3

2. Antipsychotics may be considered if TCAs fail:

   • Sulpiride 100mg four times daily or levosulpiride 25mg three times daily 1

Lifestyle and Dietary Modifications

• Regular aerobic exercise is strongly recommended for all patients 1, 3
• Dietary approach:
  • Consume 4-6 small, frequent meals of easily digestible foods 3
  • Eat slowly and chew thoroughly (at least 15 times per bite)
  • Separate liquids from solids (wait 15-30 minutes)
  • Avoid fatty, spicy, acidic, and processed foods
  • Avoid carbonated beverages and foods high in simple sugars 3

Management of Severe or Refractory Cases

• Multidisciplinary team approach including gastroenterologists, psychologists, and dietitians 1, 3
• Consider high-dose PPI trial for patients with persistent symptoms 1
• Re-evaluate diagnosis and provide reassurance 1
• Consider behavioral therapy or psychotherapy 1
• Avoid opioids and surgery as these can worsen outcomes 3

Important Clinical Considerations

• H. pylori eradication eliminates the risk of peptic ulcer mortality, even if dyspeptic symptoms persist 1
• PPIs are more effective than placebo (NNTB 11) and slightly more effective than prokinetics (NNTB 16) for symptom relief 4
• Symptom classification (ulcer-like vs. dysmotility-like) helps identify patients likely to respond to specific therapies 1
• If first-line symptomatic therapy fails, consider switching treatment approaches (e.g., from prokinetic to PPI) 1

By following this systematic approach to functional dyspepsia management, clinicians can effectively address both the underlying causes and symptomatic manifestations of the condition, improving patients' quality of life and reducing healthcare utilization.