Prescription for Functional Dyspepsia
For adults with functional dyspepsia without alarm features, first test for Helicobacter pylori using a non-invasive breath or stool test; if positive, prescribe eradication therapy, and if negative or symptoms persist after eradication, prescribe a proton pump inhibitor (PPI) at standard dose once daily for 4-8 weeks. 1, 2
Initial Diagnostic Approach
Test all patients for H. pylori using a 13C-urea breath test or stool antigen assay as these are the preferred non-invasive methods with high accuracy. 1, 2
If H. pylori is positive, provide eradication therapy immediately using triple therapy (a PPI with clarithromycin and amoxicillin) because this leads to symptom improvement in approximately 1 in 15 patients and may reduce future gastric cancer risk. 1, 2, 3
After successful eradication, reassess symptoms before starting acid suppression, as some patients will achieve complete resolution. 2
First-Line Pharmacologic Treatment
Prescribe a standard-dose PPI once daily for 4-8 weeks for patients who are H. pylori negative or whose symptoms persist after successful eradication. 1, 2
PPIs are superior to H2-receptor antagonists, antacids, and placebo for functional dyspepsia with strong evidence quality. 2, 4
The PPI trial benefits both epigastric pain syndrome (ulcer-like dyspepsia) and postprandial distress syndrome. 2
Examples include omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 40 mg once daily. 3, 4
Second-Line Treatment for Persistent Dysmotility Symptoms
If symptoms of postprandial fullness, early satiety, bloating, or upper abdominal discomfort persist after the PPI trial:
Add itopride as the first-line prokinetic agent because it has an excellent safety profile with adverse events occurring in only 1.5-3% of patients, no cardiac toxicity, and no QT prolongation. 2
Itopride can be used as add-on therapy to a PPI when acid suppression alone is insufficient. 2
Alternative prokinetics (cinitapride, mosapride) provide only modest benefit with lower quality evidence. 2
Second-Line Treatment for Persistent Pain or Refractory Symptoms
For patients who fail PPI therapy and have predominant epigastric pain or refractory symptoms:
Prescribe amitriptyline starting at 10 mg nightly and titrate slowly to 30-50 mg nightly as tolerated. 2, 5, 4
Tricyclic antidepressants are the most evidence-based option for refractory functional dyspepsia with moderate-quality evidence and response rates of 64-70%. 2, 6, 4
For patients with mixed pain and dysmotility symptoms, consider adding levosulpiride 25 mg three times daily to amitriptyline, though counsel patients about additive drowsiness and possible hyperprolactinemia. 2
Critical Clinical Caveats
Do not perform routine gastric emptying testing or 24-hour pH monitoring in patients with typical functional dyspepsia symptoms, as these add little diagnostic value. 1
Avoid repetitive or extensive diagnostic testing in the absence of alarm features, as this yields low benefit and is not cost-effective compared to empirical management. 2, 7
Establish an empathic doctor-patient relationship and explain that functional dyspepsia is a disorder of gut-brain interaction affected by diet, stress, and emotional responses, as this may reduce healthcare utilization and improve quality of life. 1
If symptoms respond to initial therapy, stop treatment after 4-8 weeks; if symptoms recur, another course of the same treatment is justified. 8
When to Consider Endoscopy or Referral
Endoscopy is not mandatory in young patients who fail empirical therapy without alarm features, as the diagnostic yield is very low. 1
Refer to gastroenterology when diagnostic doubt exists, symptoms are severe or refractory to first-line treatments, or the patient requests specialist opinion. 1, 5
For patients ≥55 years with treatment-resistant dyspepsia or those with alarm features (weight loss, dysphagia, vomiting, bleeding, family history of gastric cancer), urgent endoscopy is warranted. 1, 3