When to Give Domperidone in Non-Ulcer Dyspepsia
Domperidone should be given to patients with non-ulcer dyspepsia when their predominant symptoms are fullness, bloating, or early satiety (dysmotility-like dyspepsia), rather than epigastric pain. 1
Symptom-Based Treatment Algorithm
Step 1: Classify the Predominant Symptom Pattern
- If epigastric pain predominates (ulcer-like dyspepsia): Start with full-dose PPI therapy (e.g., omeprazole 20 mg once daily) as first-line treatment 1
- If fullness, bloating, or early satiety predominates (dysmotility-like dyspepsia): Consider a prokinetic agent like domperidone as the appropriate first-line option 1
Step 2: Dosing and Administration
- Starting dose: 10 mg three times daily before meals 2, 3
- Maximum dose: 20 mg three to four times daily if needed 2, 3
- Duration of effect: 7-14 hours per dose 2
Step 3: Pre-Treatment Cardiac Screening
Critical safety consideration: Before prescribing domperidone, you must assess cardiac risk factors due to QT prolongation risk 1, 2, 3:
- Obtain baseline ECG if patient is >60 years old, has cardiac risk factors, or will receive doses >30 mg/day 1, 2, 3
- Contraindications include: pre-existing QT prolongation, concurrent CYP3A4 inhibitors, and electrolyte abnormalities 3
- Avoid combining with other QT-prolonging medications 3
Step 4: Treatment Duration and Response Assessment
- Initial trial: 2-4 weeks of empirical therapy 1
- If symptoms improve: Consider trial withdrawal of therapy, with resumption if symptoms recur 1
- If no response: Switch treatment class (e.g., from prokinetic to PPI) since the patient may have been misclassified 1
- If still no response after switching: Consider high-dose PPI trial or refer for endoscopy 1
Evidence Supporting Domperidone Efficacy
Research demonstrates that domperidone is significantly more effective than placebo in non-ulcer dyspepsia, with a treatment success probability of 0.4029 compared to 0.2026 for H2-receptor antagonists 4. Multiple studies show 70-81% of patients achieve moderate to complete symptomatic relief 5, and domperidone effectively improves symptoms even when gastric emptying studies show no objective improvement 6.
Why Domperidone Over Metoclopramide for Extended Therapy
Domperidone is strongly preferred over metoclopramide for any therapy beyond 2 weeks because it does not readily cross the blood-brain barrier, resulting in significantly lower risk of extrapyramidal side effects (dystonia, akathisia, tardive dyskinesia) 2, 7, 3. Metoclopramide carries a high risk of potentially irreversible movement disorders and should be limited to short-term use only 7, 3.
Common Pitfalls to Avoid
- Don't use domperidone for epigastric pain-predominant dyspepsia: These patients have acid-related symptoms and should receive PPI therapy first 1
- Don't skip cardiac screening: QT prolongation is a real risk, particularly in elderly patients and those on higher doses 1, 2, 3
- Don't ignore constipation: Before attributing early satiety to gastroparesis, diagnose and treat constipation first, as this can cause similar symptoms 1
- Don't continue indefinitely without reassessment: After initial symptom control, attempt therapy withdrawal to determine if ongoing treatment is necessary 1
Special Clinical Contexts
Domperidone is also effective for early satiety in cancer patients, chemotherapy-induced nausea and vomiting, and gastroparesis 1, 2. However, the British Society of Gastroenterology explicitly states domperidone should no longer be used long-term for chronic gastrointestinal motility disorders due to cumulative cardiac risks 2.