What is the treatment for functional dyspepsia?

Treatment of Functional Dyspepsia

The treatment of functional dyspepsia should follow a stepwise approach, beginning with H. pylori testing and eradication if positive, followed by proton pump inhibitors as first-line therapy, and tricyclic antidepressants as second-line therapy for refractory cases. 1, 2

Initial Evaluation and Classification

Functional dyspepsia (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

Before initiating treatment, consider:

• For patients ≥60 years with abdominal pain and weight loss: Urgent abdominal CT to exclude pancreatic cancer 1
• For patients ≥55 years: Full blood count 2
• For patients with overlapping IBS symptoms: Coeliac serology 2

First-Line Treatment Algorithm

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
   • H. pylori eradication therapy has high-quality evidence supporting its efficacy 1

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

   • For EPS (epigastric pain predominant):

     • Proton pump inhibitors (PPIs) at standard dose (e.g., omeprazole 20mg daily)
     • Strong recommendation, high-quality evidence 1, 3
     • Use lowest effective dose as there is no dose-response relationship 1

   • For PDS (fullness, bloating, early satiety predominant):

     • Prokinetic agents where available (acotiamide, itopride, mosapride, tegaserod)
     • Weak recommendation for most prokinetics except tegaserod (moderate evidence) 1
     • Note: Cisapride is no longer recommended due to cardiac toxicity 1

3. Lifestyle Modifications (concurrent with medication):

   • Regular aerobic exercise (strong recommendation) 1, 2
   • Eating small, frequent meals (4-6 times daily) 2
   • Eating slowly and chewing thoroughly 2
   • Avoiding carbonated beverages and trigger foods 2

Second-Line Treatment

If symptoms persist despite first-line therapy:

1. Consider switching treatment approaches:

   • If PPI failed, try prokinetics or vice versa 1
   • Consider high-dose PPI trial if standard dose ineffective 1

2. Tricyclic Antidepressants (TCAs):

   • Start with low dose (e.g., amitriptyline 10mg once daily)
   • Titrate slowly to maximum of 30-50mg once daily
   • Strong recommendation, moderate-quality evidence 1
   • Requires careful explanation about rationale and side effects 1

3. Alternative Second-Line Options:

   • Antipsychotics such as sulpiride (100mg four times daily) or levosulpiride (25mg three times daily) 1
   • Histamine-2 receptor antagonists (weak recommendation, low-quality evidence) 1

Management of Severe or Refractory FD

For patients with persistent symptoms despite second-line therapy:

1. Multidisciplinary approach:

   • Involve gastroenterologists, psychologists, and dietitians 1, 2
   • Early dietitian involvement to avoid overly restrictive diet 1

2. Important cautions:

   • Avoid opioids and surgery as they can worsen outcomes and cause iatrogenic harm 1
   • Assess for eating disorders in patients with weight loss and food restriction 1
   • Avoid metoclopramide for long-term use due to risk of tardive dyskinesia and other extrapyramidal symptoms 4

Common Pitfalls to Avoid

1. Overuse of diagnostic testing:

   • Avoid routine gastric emptying testing or 24-hour pH monitoring 1, 2
   • Limit endoscopy to patients with alarm features or age ≥55 years 2

2. Treatment errors:

   • Continuing ineffective treatments without trying alternatives
   • Using metoclopramide long-term (>12 weeks) due to risk of tardive dyskinesia 4
   • Failing to provide adequate explanation of the chronic nature of the condition 2
   • Using opioids for pain management 1

The evidence shows that while PPIs are effective compared to placebo (NNTB of 11), the overall effect is modest 3. This underscores the importance of a comprehensive approach that includes lifestyle modifications alongside pharmacological interventions for optimal symptom control and improved quality of life.