What is the recommended treatment approach for patients presenting with functional dyspepsia symptoms?

Treatment Approach for Functional Dyspepsia

For patients with functional dyspepsia, a stepwise treatment approach is recommended, beginning with H. pylori testing and eradication if positive, followed by empiric acid suppression therapy with proton pump inhibitors as first-line treatment. 1, 2

Initial Evaluation

• Confirm diagnosis through:

  • Presence of bothersome epigastric pain/burning, early satiation, and/or postprandial fullness persisting for >8 weeks 2
  • Full blood count to identify anemia 2
  • Non-invasive testing for H. pylori (urea breath test or stool antigen test) 2
  • Coeliac serology for patients with overlapping IBS-type symptoms 2

• Consider endoscopy for:

  • Patients ≥55 years with dyspepsia and weight loss
  • Patients with dysphagia
  • Patients with treatment-resistant dyspepsia
  • Patients ≥60 years with abdominal pain and weight loss (consider abdominal CT to exclude pancreatic cancer) 2

First-Line Treatment Algorithm

1. Test for H. pylori and treat if positive

   • Eradication therapy is efficacious for H. pylori-positive patients 1
   • If symptoms persist after eradication, proceed to step 2

2. Empiric acid suppression therapy

   • For epigastric pain predominant symptoms (EPS subtype):

     • Proton pump inhibitors (PPIs) at lowest effective dose 1
     • Strong recommendation, high-quality evidence 1

   • For postprandial distress predominant symptoms (PDS subtype):

     • Consider prokinetics (though availability varies by region) 1, 3
     • Weak recommendation for acotiamide, itopride, and mosapride; strong recommendation for tegaserod 1

3. Regular aerobic exercise is recommended for all patients 1

Second-Line Treatment Options

If symptoms persist despite first-line treatments:

1. Consider switching treatment approach

   • If initially treated with PPI without response, try prokinetics
   • If initially treated with prokinetics without response, try PPI 1

2. Tricyclic antidepressants (TCAs)

   • 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 and side effect counseling
   • Strong recommendation, moderate-quality evidence 1

3. Consider antipsychotics in select cases

   • Options include sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily
   • Careful explanation and counseling about side effects required 1

Management of Severe or Refractory Functional Dyspepsia

For patients with severe or treatment-resistant symptoms:

1. Multidisciplinary team approach including gastroenterologist, dietitian, and behavioral health specialist 1

2. Avoid:

   • Opioids
   • Surgery
   • Overly restrictive diets 1

3. Screen for:

   • Eating disorders
   • Avoidant restrictive food intake disorder (ARFID), especially in patients with weight loss and food restriction 1

Important Considerations and Pitfalls

• Avoid routine use of gastric emptying testing or 24-hour pH monitoring 1, 2
• Avoid repeated endoscopies in patients with typical functional dyspepsia symptoms without new alarm features 2
• Dietary modifications have insufficient evidence for recommendation, including low FODMAP diets 1, 4
• Don't miss GERD: Distinguishing between functional dyspepsia and GERD is crucial as management differs 2
• Don't delay H. pylori testing: Testing should precede empiric acid suppression therapy 2
• Consider overlapping conditions such as irritable bowel syndrome which may require different approaches 2

By following this evidence-based approach, most patients with functional dyspepsia can achieve symptom control and improved quality of life.