What is the first-line treatment for an inpatient presenting with indigestion (dyspepsia)?

First-Line Treatment for Indigestion in Hospital

For an inpatient presenting with indigestion, initiate standard-dose proton pump inhibitor (PPI) therapy once daily, taken 30-60 minutes before a meal, as the first-line treatment. 1

Initial Management Algorithm

Immediate First-Line Therapy

• Start any commercially available PPI at standard dose once daily for 4-8 weeks, as all PPIs are functionally equivalent when dosed appropriately and absolute differences in efficacy are small 1
• PPIs are superior to H2-receptor antagonists, which are in turn superior to placebo, for treating dyspepsia 1, 2
• The lowest effective dose should be used, as there is no dose-response relationship demonstrated 1, 3

Concurrent H. pylori Testing

• All patients with dyspepsia should undergo non-invasive H. pylori testing using urea breath test or stool antigen test (not serology, which has lower specificity) 4, 3
• If H. pylori is positive, provide eradication therapy, which is an efficacious treatment with strong evidence 4, 3
• However, in the inpatient setting, empirical PPI therapy should be started immediately while awaiting test results, as most hospitalized patients require rapid symptom control 1, 3

Treatment Escalation for Non-Response

If Symptoms Persist After 4-8 Weeks

• Increase to twice-daily PPI dosing for an additional 4-8 weeks 1
• If symptoms persist despite twice-daily PPI for 8 weeks, proceed to endoscopy to evaluate for structural disease 1

Second-Line Therapy

• Tricyclic antidepressants (TCAs) at low doses are the most effective second-line treatment, particularly for epigastric pain syndrome 4, 3
• Start with amitriptyline 10 mg once daily at bedtime, titrated slowly to a maximum of 30-50 mg once daily 4, 3
• Careful explanation of the gut-brain neuromodulatory rationale is required, and patients should be counseled about side effects 4, 3

Important Clinical Considerations

When to Consider Urgent Endoscopy

• Patients ≥55 years with weight loss 3
• Patients >40 years from high-risk areas for gastric cancer or with family history of gastro-esophageal cancer 3
• Presence of alarm features (dysphagia, bleeding, anemia, unintentional weight loss) 4

Alternative First-Line Options

• H2-receptor antagonists may be used as an alternative, though evidence for efficacy is weaker than PPIs 4, 3
• Prokinetic agents are not recommended as first-line therapy for uninvestigated dyspepsia in the inpatient setting 5

Common Pitfalls to Avoid

Critical Safety Warnings

• Never prescribe opioids for functional dyspepsia, as they cause iatrogenic harm without benefit 3
• Avoid cisapride due to fatal cardiac arrhythmias and QT prolongation 3
• Do not perform routine gastric emptying studies or 24-hour pH monitoring for typical dyspepsia symptoms 3

Long-Term Management Considerations

• If symptoms resolve with initial therapy, taper PPI to the lowest effective dose 1
• Document appropriate indications for PPI use and consider de-prescribing in the absence of an ongoing appropriate indication 1
• Most patients with dyspepsia have non-erosive disease and should be considered for a trial of de-prescribing after symptom control is achieved 1

Multidisciplinary Approach for Refractory Cases

When to Involve Additional Specialists

• A multidisciplinary team including primary care physicians, dietitians, gastroenterologists, and psychologists is mandatory for severe or refractory functional dyspepsia 4, 3
• Early dietitian involvement is recommended to prevent overly restrictive diets that could lead to malnutrition 4, 3
• Screen patients with severe symptoms presenting with weight loss and food restriction for eating disorders, including avoidant restrictive food intake disorder (ARFID) 4, 3