What is the treatment for functional dyspepsia?

Treatment of Functional Dyspepsia

The most effective approach to treating functional dyspepsia is to test for and eradicate Helicobacter pylori infection first, followed by acid suppression therapy with proton pump inhibitors for epigastric pain syndrome (EPS) or prokinetics for postprandial distress syndrome (PDS). 1

Diagnostic Approach

• 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-esophageal cancer 1
• All patients with functional dyspepsia should undergo testing for H. pylori infection using either breath or stool tests 2

First-Line Treatment

• Test for H. pylori and provide eradication therapy if positive (test and treat strategy) 1, 2
• Regular aerobic exercise is recommended for all patients with functional dyspepsia 1
• For patients without H. pylori or those with persistent symptoms after eradication:
  • For EPS (predominant epigastric pain): Use proton pump inhibitors (PPIs) at the lowest effective dose 1, 3
  • For PDS (predominant fullness, bloating, early satiety): Use prokinetic agents like metoclopramide (with caution regarding side effects) 1, 4
• Avoid foods that trigger symptoms while maintaining adequate nutrition 1, 2

Second-Line Treatment

• Tricyclic antidepressants at low doses (e.g., amitriptilina 10 mg daily) are recommended when first-line therapies fail, particularly effective for EPS 1, 2
• Consider switching therapy approaches (from PPI to prokinetic or vice versa) if initial treatment is ineffective 4
• Histamine-2 receptor antagonists may be helpful as an alternative to PPIs or as "on-demand" therapy for intermittent symptoms 4, 5

Management of Refractory Cases

• Refer to gastroenterology when there is diagnostic doubt or symptoms are severe/refractory to first-line treatments 1
• Consider combination therapies, such as dual therapy with different medication classes 1, 2
• A multidisciplinary approach involving primary care physicians, dietitians, gastroenterologists, and psychologists is recommended for severe, refractory cases 1, 2
• Psychotherapy, including cognitive behavioral therapy and hypnotherapy, can be effective for patients with severe symptoms 6

Common Pitfalls and Caveats

• Avoid prescribing overly restrictive diets that may lead to malnutrition or abnormal eating behaviors 1, 2
• Be aware that specialized diets, including low FODMAP diets, have insufficient evidence for routine recommendation in functional dyspepsia 1
• Gastric emptying testing or 24-hour pH monitoring should not be routinely performed in patients with typical functional dyspepsia symptoms 1
• Avoid using cinitaprida with other medications that may prolong the QT interval 1, 2
• The symptom response to H. pylori eradication therapy in patients with functional dyspepsia is often modest, but still recommended as first-line approach 4

Emerging Therapies

• Newer agents such as acotiamide for PDS, fundus-relaxing 5-HT1A agonists for early satiation, and mirtazapine for functional dyspepsia with weight loss show promise but require further evaluation 3, 6
• Alternative therapies including virtual reality are gaining recognition as potentially effective treatments 6