What is the recommended follow-up approach for patients with functional dyspepsia (FD) after initiating treatment?

Follow-Up Approach for Functional Dyspepsia After Treatment Initiation

After initiating treatment for functional dyspepsia, reassess symptom response at 4-8 weeks and implement a therapy withdrawal test if symptoms are controlled; if symptoms persist, switch therapeutic class or refer to gastroenterology for refractory cases. 1

Initial Follow-Up Timeline and Assessment

• Reassess patients at 4-8 weeks after starting initial therapy to determine treatment response 1, 2
• If symptoms are controlled with initial empiric treatment (PPI or H. pylori eradication), stop treatment after 4-8 weeks to perform a therapy withdrawal test 1, 2
• When symptoms recur after withdrawal, repeat the same successful treatment rather than switching agents 1, 2
• On-demand therapy with the successful agent is a valid long-term management strategy for patients with intermittent symptoms 1

Management of Treatment Failures

First-Line Treatment Failures

• If symptoms persist after 2-4 weeks of initial PPI therapy, consider changing drug class or dosing before proceeding to further investigation 2
• Switch therapeutic approach based on symptom pattern: if PPI fails, switch to prokinetic agent (or vice versa) 1, 3
• For patients who received H. pylori eradication, trial acid suppression if symptoms persist despite successful eradication 2

When to Escalate Care

• Refer to gastroenterology when symptoms are severe, refractory to first-line treatments, or when diagnostic doubt exists 4
• Referral is also appropriate when the patient specifically requests specialist opinion 4

Specific Follow-Up Based on Initial Treatment

After H. pylori Eradication

• Confirm successful eradication ONLY in patients at increased risk of gastric cancer (age >40 years from high-risk areas, family history of gastro-oesophageal cancer) 4, 1
• Do not routinely confirm eradication in average-risk patients 4

After Acid Suppression Therapy

• Use the lowest PPI dose that controls symptoms as there is no dose-response relationship 4, 1
• If symptoms are controlled, attempt withdrawal at 4-8 weeks rather than continuing indefinitely 1, 2

Red Flags Requiring Urgent Re-evaluation

• Consider non-urgent endoscopy in patients ≥55 years with treatment-resistant dyspepsia or those with elevated platelet count, nausea, or vomiting 4, 1
• Urgent abdominal CT scanning is warranted in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 4, 1

Second-Line Treatment Initiation

• If first-line therapies fail, initiate tricyclic antidepressants (TCAs) as gut-brain neuromodulators starting with low doses (amitriptyline 10 mg once daily) and titrating slowly to maximum 30-50 mg once daily 4, 1
• Provide careful explanation about the rationale for TCA use and counsel patients about side effects before initiation 4
• Antipsychotics such as sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily may be considered as alternative second-line options 4, 1

Ongoing Supportive Management

• Reinforce regular aerobic exercise at every follow-up visit as this is recommended for all FD patients 4, 1
• Maintain therapeutic relationship and shared understanding throughout follow-up, as this reduces healthcare utilization and improves quality of life 4
• Re-explain the diagnosis as a disorder of gut-brain interaction when symptoms persist, addressing diet, stress, and behavioral responses 4

What NOT to Do During Follow-Up

• Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical FD symptoms 4
• Do not continue empiric drug therapy beyond 8-12 weeks without reassessment, given the absence of causally directed treatment 5
• Avoid indefinite PPI therapy without attempting withdrawal in responders 1, 2

Specialized Clinic Referral

• Ideally, patients with FD referred to secondary care should be managed in specialist clinics with access to interested clinicians, dietetic support, efficacious drugs, and gut-brain behavioral therapies 4
• For patients with severe symptoms and refractoriness, psychotherapy is an effective treatment option that should be considered 6