What is the treatment for functional dyspepsia?

Treatment of Functional Dyspepsia

The first-line treatment for functional dyspepsia should be proton pump inhibitors (PPIs) at standard dose, especially for patients with epigastric pain predominant symptoms, while prokinetics are recommended for patients with fullness, bloating, and early satiety predominant symptoms. 1

Initial Assessment and Treatment Strategy

Step 1: Test for H. pylori

• 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 is an efficacious treatment with strong evidence 2

Step 2: First-line Pharmacological Treatment

Based on predominant symptom pattern:

For epigastric pain predominant symptoms:

• PPIs at standard dose (e.g., omeprazole 20mg daily) 1
• Use lowest effective dose that controls symptoms 2
• Strong recommendation with high-quality evidence 1

For fullness, bloating, and early satiety predominant symptoms:

• Prokinetic agents (e.g., metoclopramide) 1
• Weak recommendation with low-quality evidence for most prokinetics 2
• Important caution: With metoclopramide, limit treatment to short-term use due to risk of tardive dyskinesia and other extrapyramidal symptoms 3

Alternative first-line option:

• Histamine-2 receptor antagonists (H2RAs) 2
• Weak recommendation with low-quality evidence 2
• May be particularly effective within first 2 weeks of treatment 4

Second-line Treatment Options

If first-line treatment fails:

Step 3: Switch Medication Class

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

Step 4: Tricyclic Antidepressants (TCAs)

• Strong recommendation with moderate-quality evidence 2, 1
• Start with low dose (e.g., amitriptyline 10mg once daily)
• Titrate slowly to maximum of 30-50mg once daily
• Careful explanation of rationale for use is required 2

Step 5: Alternative Second-line Options

• Antipsychotics (e.g., sulpiride 100mg four times a day or levosulpiride 25mg three times a day) 2
• Weak recommendation with low-quality evidence

Dietary and Lifestyle Modifications

• Eat small, frequent meals (4-6 times a day) 1
• Eat slowly and chew food thoroughly 1
• Separate liquids from solids 1
• Ensure adequate hydration (at least 1.5L of fluids daily) 1
• Avoid carbonated beverages, foods high in simple sugars, and trigger foods 1
• Consider low FODMAP diet (weak recommendation, very low-quality evidence) 2
• Regular aerobic exercise is recommended to help reduce anxiety symptoms 1

Management of Severe or Refractory Functional Dyspepsia

• Involve multidisciplinary support team (strong recommendation) 2, 1
• Early dietitian involvement to avoid overly restrictive diet 2, 1
• Avoid opioids and surgery as they can worsen outcomes and cause iatrogenic harm 2, 1
• Assess for eating disorders in patients with weight loss and food restriction 2

Important Cautions and Monitoring

PPI Therapy Cautions

• Use lowest effective dose for shortest duration 5
• Monitor for potential adverse effects with long-term use:
  • Acute tubulointerstitial nephritis
  • Clostridium difficile-associated diarrhea
  • Bone fracture risk
  • Vitamin B12 deficiency
  • Hypomagnesemia 5

Prokinetic Therapy Cautions

• Risk of extrapyramidal symptoms and tardive dyskinesia with metoclopramide
• Higher risk in elderly, women, diabetics, and with longer duration of treatment
• Limit metoclopramide use to less than 12 weeks 3
• Monitor for parkinsonian-like symptoms, depression, and neuroleptic malignant syndrome 3

Treatment Algorithm Summary

1. Test for H. pylori and eradicate if positive
2. For epigastric pain: Start PPI
3. For fullness/bloating: Start prokinetic (with caution)
4. If no response, switch medication class
5. If still no response, add TCA at low dose
6. For refractory cases, consider multidisciplinary approach
7. Implement dietary and lifestyle modifications throughout treatment

Remember that functional dyspepsia is often chronic with fluctuating symptoms 6, and treatment should focus on symptom management and improving quality of life.