What is the treatment for functional dyspepsia?

Treatment of Functional Dyspepsia

The first-line treatment for functional dyspepsia should include H. pylori testing and eradication if positive, followed by proton pump inhibitors (PPIs) or prokinetics depending on symptom pattern. 1

Diagnostic Approach

• Functional dyspepsia (FD) is characterized by symptoms such as upper abdominal pain, burning, early satiety, or postprandial fullness without structural abnormalities 2
• A full blood count should be performed in patients ≥55 years with dyspepsia and coeliac serology in patients with overlapping IBS-type symptoms 1
• Urgent endoscopy is warranted in patients ≥55 years with weight loss, or those >40 years from high-risk areas for gastric cancer or with family history of gastro-oesophageal cancer 1
• Non-urgent endoscopy should be considered in patients ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting 1
• Urgent abdominal CT scanning should be considered in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1

First-Line Treatment

• All patients with FD should be offered non-invasive testing for Helicobacter pylori ("test and treat") and, if infected, given eradication therapy 1, 2
• Regular aerobic exercise is recommended for all patients with FD 1
• Patients without H. pylori infection should be offered empirical acid suppression therapy 1
• Proton pump inhibitors (PPIs) are effective for FD, especially for epigastric pain syndrome (EPS) subtype, using the lowest effective dose 1, 3
• Histamine-2 receptor antagonists may be efficacious for FD and are well tolerated 1, 4
• Prokinetic agents may be beneficial for patients with postprandial distress syndrome (PDS) subtype, characterized by fullness, bloating, early satiety or nausea 1, 3

Second-Line Treatment

• Tricyclic antidepressants at low doses (e.g., amitriptilina 10mg daily) are recommended as second-line therapy, particularly for EPS 2, 4
• Patients should avoid foods that trigger symptoms while being cautious not to adopt overly restrictive diets that could lead to malnutrition 1, 2
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets, for FD 1

Management of Refractory Cases

• Referral to gastroenterology is appropriate when there is diagnostic doubt, symptoms are severe or refractory to first-line treatments 1
• Patients with severe symptoms that don't respond to standard treatments should be managed by a multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists 1, 2
• Combination therapies may be considered, such as dual therapy with different medication classes 2
• Psychological therapies, including cognitive behavioral therapy and hypnotherapy, are gaining recognition as effective treatments for FD and can be used alone or in combination with medications 5

Treatment Algorithm Based on Symptom Subtype

1. For all patients: Test for H. pylori and eradicate if positive 1, 2
2. For EPS (predominant epigastric pain):
   • First line: PPI or H2 receptor antagonist 1, 4
   • Second line: Low-dose tricyclic antidepressant 2, 4
3. For PDS (predominant fullness, bloating, early satiety):
   • First line: Prokinetic agent 1, 3
   • Second line: Switch to PPI or add tricyclic antidepressant 4

Common Pitfalls and Caveats

• Avoid prescribing overly restrictive diets that may lead to malnutrition or abnormal eating habits 1, 2
• Be aware that gastric emptying testing or 24-hour pH monitoring should not be routinely performed in patients with typical FD symptoms 1
• Recognize that H. pylori eradication, while recommended, may have limited impact on symptoms for many patients 3
• Metoclopramide, if used as a prokinetic, should be prescribed for short-term treatment with discussion of potential side effects 4
• Avoid using cinitaprida with other medications that may prolong the QT interval 2