What are the treatment options for functional dyspepsia?

Treatment for Functional Dyspepsia

The first-line treatment for functional dyspepsia should include H. pylori testing and treatment if positive, followed by acid suppression therapy with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists, with tricyclic antidepressants as effective second-line therapy. 1, 2

Diagnosis and Classification

Functional dyspepsia (FD) is diagnosed in patients with:

• Bothersome epigastric pain or burning
• Early satiation and/or postprandial fullness
• Symptoms lasting >8 weeks
• No structural abnormalities on investigation 1

FD 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 2

Initial Evaluation

• For patients ≥55 years: Full blood count recommended 1
• For patients with overlapping IBS symptoms: Coeliac serology recommended 1
• For patients ≥60 years with abdominal pain and weight loss: Consider urgent abdominal CT to exclude pancreatic cancer 1
• For most patients without alarm features: Non-invasive H. pylori testing is recommended before endoscopy 1

Treatment Algorithm

First-Line Treatments

1. H. pylori "Test and Treat" Strategy

   • Test all patients for H. pylori infection
   • If positive, provide eradication therapy
   • Confirm eradication only in patients with increased risk of gastric cancer 1

2. Acid Suppression Therapy

   • For H. pylori-negative patients or those with persistent symptoms after eradication
   • PPIs: Strong evidence of efficacy; use lowest effective dose 1
   • H2-receptor antagonists: Alternative option with moderate efficacy 1

3. Lifestyle Modifications

   • Regular aerobic exercise is strongly recommended for all FD patients 1, 2
   • Dietary recommendations:
     • Small, frequent meals (4-6 times daily)
     • Eat slowly and chew thoroughly
     • Avoid fatty, spicy, acidic foods and carbonated beverages
     • Include easily digestible foods (rice, bread, bananas, apples, yogurt) 2, 3

4. Prokinetics (where available)

   • Acotiamide, itopride, mosapride (weak recommendation)
   • Tegaserod (stronger evidence) 1

Second-Line Treatments

1. Tricyclic Antidepressants (TCAs)

   • Start with low dose (e.g., amitriptyline 10mg daily)
   • Titrate slowly to 30-50mg daily as needed
   • Provide careful explanation about their use as gut-brain neuromodulators
   • Counsel patients about side effects (dry mouth, constipation, drowsiness) 1, 2

2. Antipsychotics (if TCAs ineffective or not tolerated)

   • Sulpiride 100mg four times daily or
   • Levosulpiride 25mg three times daily 1, 2

Special Considerations

• Referral to gastroenterology is appropriate when:

  • Diagnostic uncertainty exists
  • Symptoms are severe or refractory to first-line treatments
  • Patient requests specialist opinion 1

• Avoid routine use of:

  • Gastric emptying testing
  • 24-hour pH monitoring
  • Opioids
  • Surgery 1, 2

• Multidisciplinary approach for refractory cases:

  • Specialist clinic with interested clinician
  • Dietetic and lifestyle support
  • Access to gut-brain behavioral therapies 1, 2

Treatment Efficacy and Pitfalls

• H. pylori eradication: Effective but may cause more adverse events than control therapy 1, 4
• PPIs and H2-blockers: Effective for many patients but not all will respond 1, 5
• TCAs: Moderate evidence of efficacy but side effects may limit use 1, 6
• Dietary interventions: Limited evidence for specific diets including low FODMAP diet 1, 3

Common Pitfalls to Avoid

1. Failure to explain the diagnosis properly: Establishing an effective doctor-patient relationship and explaining FD as a disorder of gut-brain interaction is crucial 1

2. Overuse of endoscopy: In the absence of alarm features, endoscopy has low yield in typical FD patients under 55 years 1, 5

3. Inadequate trial of medications: Treatments often need 4-8 weeks to show full benefit

4. Ignoring psychological factors: Psychological comorbidities are common and may require specific management 6, 5

5. Prescribing opioids: These can worsen outcomes and cause iatrogenic harm 2

The management of FD remains challenging due to its complex pathophysiology, but a structured approach focusing on H. pylori eradication, acid suppression, neuromodulators, and lifestyle modifications can significantly improve symptoms and quality of life for most patients.