What is the initial treatment for functional dyspepsia?

Initial Treatment for Functional Dyspepsia

The first-line treatment for functional dyspepsia should be testing for Helicobacter pylori infection, and if positive, providing antibiotic treatment to eradicate the infection. 1, 2

Diagnostic Approach and Initial Management

Functional dyspepsia (FD) is characterized by symptoms such as epigastric pain/burning, postprandial fullness, and early satiation without structural abnormalities, affecting approximately 7% of the global population. The condition is classified into two subtypes:

• Epigastric pain syndrome (EPS): Characterized by epigastric pain or burning
• Postprandial distress syndrome (PDS): Characterized by early satiety and fullness after meals

Step 1: H. pylori Testing and Treatment

• All patients with FD should undergo testing for H. pylori infection
• If positive, provide appropriate antibiotic therapy to eradicate the infection
• Reassess symptoms after successful eradication

Pharmacological Treatment Algorithm

If H. pylori negative or symptoms persist after eradication:

1. For predominant epigastric pain (EPS subtype):

   • Begin with acid suppressants: Proton pump inhibitors (PPIs) or H2-receptor antagonists 1, 3

2. For predominant fullness, bloating, early satiety (PDS subtype):

   • Begin with prokinetic agents (e.g., metoclopramide) 3
   • Note: Use metoclopramide for short-term only with careful discussion of potential side effects

3. If initial therapy fails:

   • Switch therapy (from PPI to prokinetic or vice versa)
   • Consider tricyclic antidepressants (TCAs) for refractory symptoms 2
     • Start with amitriptyline 10 mg daily
     • Titrate slowly to 30-50 mg daily as needed
     • Explain these are used as gut-brain neuromodulators, not as antidepressants

Non-Pharmacological Approaches

Dietary Modifications

• Consume small, frequent meals (4-6 small meals rather than 3 large ones) 2, 4
• Eat slowly and chew thoroughly (at least 15 times per bite)
• Avoid trigger foods: fatty, spicy, acidic, and processed foods
• Separate liquids from solids (wait 15 minutes before and 30 minutes after meals to drink)
• Avoid carbonated beverages

Lifestyle Modifications

• Regular aerobic exercise is strongly recommended 2
• Cessation of smoking
• Minimize alcohol and coffee intake 3

Management of Refractory Cases

For patients with persistent symptoms despite initial treatments:

• Re-evaluate for other disorders
• Consider multidisciplinary team approach including gastroenterologists, psychologists, and dietitians 2
• Early dietitian involvement is recommended for patients with severe symptoms to avoid overly restrictive diets 1
• Consider combination therapies for severe cases 5

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure proper differentiation from gastroesophageal reflux disease and irritable bowel syndrome 3
2. Overinvestigation: Minimize extensive or repetitive testing in the absence of alarm features 6
3. Opioid prescription: Avoid opioids as they can worsen outcomes 2
4. Surgical interventions: Surgery is not recommended and can cause iatrogenic harm 2
5. Delayed recognition of eating disorders: Assess for eating disorders in patients with significant weight loss and food restriction 1

By following this structured approach to the management of functional dyspepsia, clinicians can provide effective symptom relief while minimizing unnecessary investigations and treatments.