Write a prescription for an adult patient with functional dyspepsia and no known contraindications.

Prescription for Functional Dyspepsia

Start with a proton pump inhibitor (PPI) at standard dose—omeprazole 20 mg once daily for 4-8 weeks—as this is the most effective first-line pharmacological treatment for functional dyspepsia, particularly for patients with ulcer-like or reflux-like symptoms. 1, 2

Initial Assessment and Testing

Before prescribing, verify the patient has been tested for H. pylori infection using a non-invasive test (13C urea breath test or stool antigen test). 1

• If H. pylori positive: Prescribe eradication therapy first (strong recommendation, high-quality evidence), as this is an efficacious treatment that improves quality of life, though adverse events are more common than placebo. 1, 2
• If H. pylori negative or symptoms persist after eradication: Proceed with PPI therapy as outlined below. 1

First-Line Prescription Options

Option 1: Proton Pump Inhibitor (Preferred)

Omeprazole 20 mg once daily for 4-8 weeks 1, 2

• This achieves complete symptom relief in 38% of patients versus 28% with placebo. 3
• Particularly effective for ulcer-like dyspepsia (40% response) and reflux-like dyspepsia (54% response). 3
• Use the lowest dose that controls symptoms; double-dose omeprazole does not increase benefit. 1
• Well tolerated with high-quality evidence supporting efficacy. 1

Option 2: H2-Receptor Antagonist (Alternative)

If PPI is contraindicated or patient prefers alternative:

• Famotidine 20 mg twice daily or equivalent H2-receptor antagonist 1
• Weak recommendation with low-quality evidence, but probably more effective than placebo. 1

Option 3: Prokinetic Agent (For Postprandial Distress)

If symptoms are predominantly postprandial fullness, early satiation, or bloating:

• Acotiamide 100 mg three times daily before meals 4, 2
• Specifically beneficial for postprandial distress syndrome through dual mechanisms: muscarinic receptor antagonism and acetylcholinesterase inhibition. 4
• Well-tolerated with superior safety profile compared to domperidone (avoid domperidone due to cardiac safety concerns). 2
• Note: Availability is limited in many countries. 2

Second-Line Prescription (If First-Line Fails After 4-8 Weeks)

Amitriptyline 10 mg once daily at bedtime, titrate slowly to 30-50 mg daily as tolerated 1, 2

• Strong recommendation with moderate-quality evidence as second-line therapy. 1, 2
• Functions as a "gut-brain neuromodulator" rather than antidepressant—explain this rationale to improve adherence. 2
• Start low (10 mg) to minimize side effects: dry mouth (25%), somnolence (54%), constipation (13%), weight gain (12%). 2
• Titrate slowly over weeks to months based on symptom response and tolerability. 1, 2
• Particularly useful if comorbid anxiety or depression exists, as it treats both conditions. 2

Adjunctive Non-Pharmacological Recommendations

• Advise regular aerobic exercise (strong recommendation). 1
• Avoid overly restrictive diets that may lead to malnutrition or disordered eating. 1, 2
• Insufficient evidence to recommend low-FODMAP diet routinely. 1

Common Pitfalls to Avoid

• Do not skip first-line therapy: Use amitriptyline only after adequate trial of PPI or H. pylori eradication. 2
• Do not start amitriptyline at high doses: Begin at 10 mg to improve tolerability. 2
• Do not use domperidone: Cardiac safety concerns including QT prolongation outweigh benefits. 2
• Do not prescribe opioids: These should be avoided to minimize iatrogenic harm in refractory cases. 1
• Assess response early: Symptom improvement during the first week of PPI therapy predicts 4-week outcome. 5

Refractory Cases

If symptoms persist despite PPI and amitriptyline trials:

• Consider combination therapy (e.g., PPI + amitriptyline). 6
• Refer to multidisciplinary team including gastroenterology, dietitian, and psychology. 1, 2
• Screen for eating disorders including avoidant restrictive food intake disorder (ARFID) if weight loss or food restriction present. 1