What is the recommended treatment for indigestion?

Treatment for Indigestion (Functional Dyspepsia)

All patients with indigestion should first undergo testing for Helicobacter pylori and receive eradication therapy if positive, followed by a trial of proton pump inhibitor (PPI) therapy if symptoms persist. 1, 2

Initial Diagnostic Considerations

Before initiating treatment, certain patients require urgent evaluation 2:

• Urgent endoscopy is warranted for 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 2
• Urgent abdominal CT should be considered in patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 2
• Perform full blood count in patients ≥55 years and coeliac serology in those with overlapping IBS-type symptoms 2

First-Line Treatment Algorithm

Step 1: H. pylori Testing and Eradication

Test all patients for H. pylori using stool or breath testing and provide eradication therapy if positive. 1, 2 This provides modest but meaningful symptom improvement regardless of symptom subtype 2.

Step 2: Lifestyle Modifications

• Regular aerobic exercise is recommended for all patients 2
• Avoid specific foods that trigger symptoms, but avoid overly restrictive diets that could lead to malnutrition or abnormal eating habits 1, 2
• There is insufficient evidence to recommend specialized diets, including low FODMAP diets 2

Step 3: Empirical Acid Suppression

For patients who remain symptomatic after H. pylori eradication or who test negative 1, 2:

Proton pump inhibitors (PPIs) are the first-line pharmacological treatment, particularly effective for epigastric pain syndrome subtype 2:

• Use the lowest effective dose 2
• Standard dosing: omeprazole 20 mg or lansoprazole 30 mg once daily before meals 3
• Trial for 4-8 weeks 1

Alternative: H2 receptor antagonists can be used if PPIs are not tolerated 2:

• Ranitidine 150 mg twice daily (note: currently withdrawn from many markets) 4
• These provide effective symptomatic relief, particularly in milder disease, but become less effective over time 5

Second-Line Treatment

Tricyclic antidepressants at low doses are recommended as second-line therapy, particularly for epigastric pain syndrome 2:

• Amitriptyline or trimipramine, especially when insomnia is prominent 1
• May aggravate constipation 1

Adjunctive Pharmacotherapy Based on Symptom Pattern

Rather than empiric use, personalize adjunctive agents to specific symptoms 1:

• For breakthrough symptoms: Alginate antacids (particularly useful for post-prandial symptoms and in patients with hiatal hernia) 1
• For nocturnal symptoms: H2 receptor antagonists at bedtime (ranitidine 300 mg, famotidine 40 mg) 1, 6
  • Adding bedtime H2-blocker to twice-daily PPI enhances nocturnal gastric pH control and decreases nocturnal acid breakthrough 6
  • However, use is limited by tachyphylaxis 1
• For regurgitation or belch-predominant symptoms: Baclofen (GABA-B agonist), though often limited by CNS and GI side effects 1
• For coexistent gastroparesis: Prokinetic agents 1
• For dyspepsia with heartburn: Consider antacid therapy with H2 blocker or proton pump inhibitor 1

Management of Refractory Cases

Refer to gastroenterology when there is diagnostic doubt, severe symptoms, or symptoms refractory to first-line treatments. 2

For severe refractory symptoms 2:

• Manage with multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists 2
• Screen for eating disorders including avoidant restrictive food intake disorder (ARFID) in patients with weight loss and food restriction 2
• Refer to dietitian early to prevent overly restrictive diets 2
• Consider pharmacologic neuromodulation and/or behavioral therapy (cognitive behavioral therapy, hypnotherapy, diaphragmatic breathing) 1

Critical Safety Warnings

Avoid opioids and surgery in patients with severe or refractory functional dyspepsia to minimize iatrogenic harm. 2

Important Caveats

• PPI considerations: Use shortest duration appropriate; long-term use (>1 year) associated with increased risk of fundic gland polyps, hypomagnesemia (especially >3 years), vitamin B12 deficiency, and increased risk of C. difficile infection 3
• Avoid combining omeprazole with clopidogrel due to reduced antiplatelet activity 3
• H2-blocker onset vs. duration: Antacids provide faster onset (5.8 minutes vs. 65-70 minutes for H2-blockers) but shorter duration of action 7. H2-blockers are better for symptom prophylaxis, while antacids are superior for rapid pain relief 7
• Establish empathic relationship: Explain that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition or "all in their head" 2