What is the recommended management approach for chronic dyspepsia?

Management of Chronic Dyspepsia

For chronic dyspepsia, initiate treatment with H. pylori testing and eradication if positive, followed by a trial of proton pump inhibitor (PPI) therapy at full dose (omeprazole 20 mg once daily) for 4-8 weeks if symptoms persist. 1, 2

Initial Assessment and Testing

• Test all patients for H. pylori using a validated noninvasive test (urea breath test or stool antigen test), as eradication is an effective first-line treatment for H. pylori-positive functional dyspepsia 1, 2
• Consider urgent endoscopy in patients ≥55 years with alarm features (weight loss, vomiting, dysphagia, or gastrointestinal bleeding) 1
• Consider urgent abdominal CT in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1
• In patients without alarm features and age <55 years, endoscopy is not mandatory as the diagnostic yield is low 1, 3

First-Line Pharmacological Treatment

H. pylori-Positive Patients

• Provide H. pylori eradication therapy as first-line treatment with strong evidence supporting this approach 2
• Confirm successful eradication only in patients at higher risk of gastric cancer 1
• If symptoms persist after successful eradication, proceed to empiric acid suppression 1, 3

H. pylori-Negative Patients or After Eradication

• Start omeprazole 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks as the standard first-line therapy 1, 2
• PPIs are more effective than H2-receptor antagonists (H2RAs) for symptom relief (RR 0.63,95% CI 0.47 to 0.85) 4
• PPIs are also more effective than antacids (RR 0.72,95% CI 0.64 to 0.80) 4
• H2RAs (such as famotidine) may be used as an alternative first-line option, though with weaker evidence 2

Symptom-Based Treatment Selection

• For ulcer-like dyspepsia (predominant epigastric pain): full-dose PPI is the preferred first option 1
• For dysmotility-like dyspepsia (predominant fullness, early satiety, bloating): consider a prokinetic agent such as acotiamide if available 1, 2

Management of Treatment Response

If Symptoms Improve

• After 4-8 weeks of successful treatment, attempt therapy withdrawal to assess ongoing need 1
• If symptoms recur, restart the same treatment that was effective 1
• On-demand therapy (taking medication only when symptoms occur) is a valid long-term strategy 1
• Taper to the lowest effective dose that controls symptoms 1

If Symptoms Persist on Initial PPI Therapy

• Escalate to twice-daily PPI dosing (omeprazole 20 mg before breakfast and dinner) if symptoms persist after 4 weeks on once-daily dosing 1
• Assess response at 4-8 weeks after escalation 1
• If the patient was on H2RA therapy (such as famotidine) for 9 weeks without adequate response, switch to full-dose PPI rather than continuing the H2RA indefinitely 1

Second-Line Treatment for Refractory Symptoms

Tricyclic Antidepressants (TCAs)

• If symptoms persist despite adequate PPI therapy, initiate low-dose amitriptyline 10 mg once daily as the preferred second-line treatment 5, 2
• Titrate slowly to a maximum of 30-50 mg once daily based on response and tolerability 5, 2
• Provide careful explanation about the rationale (neuromodulation of visceral pain, not depression treatment) and counsel about side effects (dry mouth, constipation, drowsiness) 5
• TCAs have moderate-quality evidence supporting their use in functional dyspepsia 5, 2

Prokinetic Agents

• If TCAs are not tolerated or contraindicated, consider acotiamide (if available) as it has a superior safety profile compared to other prokinetics 2
• Avoid domperidone due to cardiac safety concerns including QT prolongation and risk of serious arrhythmias 2
• The evidence for prokinetics is weaker than for TCAs (low-quality evidence) 2

Antipsychotic Agents

• Sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily may be considered as second-line options 5
• Provide careful explanation about rationale and counsel about side effects before initiating 5

Management of Severe or Refractory Dyspepsia

Multidisciplinary Approach

• Involve a multidisciplinary support team for patients with severe or refractory symptoms despite the above treatments 5
• Arrange early dietitian involvement to prevent overly restrictive diets that can worsen nutritional status 5
• Assess patients presenting with weight loss and food restriction for eating disorders, including avoidant restrictive food intake disorder (ARFID) 5

Treatments to Avoid

• Do not prescribe opioids for chronic dyspepsia as they cause harm without benefit 5
• Do not refer for surgery as there is no surgical treatment for functional dyspepsia 5
• Do not pursue additional endoscopy unless new alarm features develop 1

Adjunctive Measures

• Recommend regular aerobic exercise for all patients with functional dyspepsia 1
• Consider behavioral therapies or psychotherapy in patients with refractory symptoms and psychological comorbidity 1
• If symptoms persist despite twice-daily PPI therapy after 4-8 weeks, consider prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm whether acid reflux is the underlying mechanism 1

Common Pitfalls to Avoid

• Do not continue H2RA therapy indefinitely hoping for delayed response after 8-9 weeks of treatment; escalate to PPI instead 1
• Do not let concerns about PPI-associated adverse events drive treatment decisions when there is a clear indication for use, as PPIs are safe for dyspepsia treatment 1
• Do not pursue combination therapy with PPI plus prokinetics as first-line treatment, as it shows no additional benefit over PPI alone (RR 0.85,95% CI 0.68 to 1.08) 4
• Do not use antacids as monotherapy, as they are no more effective than placebo 6