What is the initial treatment for functional dyspepsia?

Initial Treatment for Functional Dyspepsia

All patients with functional dyspepsia should first undergo H. pylori testing and receive eradication therapy if positive, followed by a trial of proton pump inhibitors (PPIs) at the lowest effective dose if symptoms persist. 1, 2

First-Line Treatment Algorithm

Step 1: H. pylori Testing and Eradication

• Test all patients with functional dyspepsia for H. pylori using non-invasive methods (stool antigen test or urea breath test) 1, 3, 2
• If positive, provide eradication therapy immediately—this is the most important initial intervention regardless of symptom subtype 1, 2
• Eradication therapy is highly efficacious with strong evidence, though adverse events are more common than placebo 1
• Recognize that symptom improvement may be modest or delayed, but eradication eliminates ulcer risk and mortality 4

Step 2: Lifestyle Modifications

• Advise all patients to engage in regular aerobic exercise (strong recommendation despite very low quality evidence) 1, 2
• Counsel patients to avoid specific foods that trigger their symptoms 3, 2
• Critical pitfall: Do not prescribe overly restrictive diets—these can lead to malnutrition, abnormal eating habits, or avoidant restrictive food intake disorder (ARFID) 1, 3, 2
• There is insufficient evidence to recommend low FODMAP or other specialized diets 1, 2

Step 3: Empirical Acid Suppression

• For patients without H. pylori or those with persistent symptoms after eradication, initiate PPI therapy 2, 4
• PPIs are highly efficacious with strong evidence and are well-tolerated 1
• Use the lowest dose that controls symptoms (e.g., omeprazole 20 mg once daily)—there is no dose-response relationship 1, 4
• PPIs are particularly effective for epigastric pain syndrome (EPS) subtype 2, 4
• Alternative: H2-receptor antagonists may be efficacious and are well-tolerated, though evidence is weaker (weak recommendation, low quality evidence) 1, 4

Step 4: Consider Prokinetics (Geography-Dependent)

• Prokinetics may be efficacious, particularly for postprandial distress syndrome (PDS) with bloating, early satiation, and fullness 1, 4
• Important caveat: Efficacy varies by drug class, and many prokinetics are unavailable outside Asia and the USA 1
• Tegaserod has the strongest evidence (strong recommendation, moderate quality) 1
• Acotiamide, itopride, and mosapride have weaker evidence (weak recommendation, low quality) 1
• Metoclopramide is available in most regions but requires short-term use with careful discussion of side effects 5

When to Switch or Escalate Therapy

Treatment Failure Strategy

• If no response to initial PPI therapy, consider switching to a prokinetic agent (or vice versa), as symptom misclassification is possible 4
• For fluctuating symptoms, attempt a treatment withdrawal trial after initial symptom control, then re-treat with the successful medication if symptoms recur 4
• Do not use acid suppression without H. pylori eradication in H. pylori-positive patients—this represents inadequate treatment of possible ulcer disease 4

Referral Indications

• Refer to gastroenterology when there is diagnostic doubt, severe symptoms, or symptoms refractory to first-line treatments 1, 2
• Ideally, manage referred patients in specialist clinics with access to dietetic support, efficacious drugs, and gut-brain behavioral therapies 1

Common Pitfalls to Avoid

• Do not routinely perform gastric emptying testing or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms 1, 2
• Avoid prescribing overly restrictive diets that may cause malnutrition or trigger eating disorders 1, 3, 2
• Do not combine cinitapride with other medications that prolong the QT interval 3, 2
• Establish an empathic relationship and explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head" 2

Evidence Quality Context

The British Society of Gastroenterology 2022 guidelines provide the most comprehensive and recent framework 1. The recommendation for H. pylori eradication carries high-quality evidence with a strong recommendation, while PPI therapy also has high-quality evidence supporting its use 1. The lifestyle modification recommendations, particularly exercise, have very low quality evidence but are strongly recommended due to their safety profile and potential benefits 1. This treatment hierarchy is consistently supported across multiple international guidelines 3, 2, 4.