Review article: current treatment options and management of functional dyspepsia

Abstract

Background: Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

Aim: To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

Results: The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

Conclusions: A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

Figure 1

Proposed treatment algorithm for FD. In this algorithm the patient with dyspepsia undergoes an upper endoscopy which, by definition, has to be grossly normal. If biopsies for Helicobacter pylori (HP) were performed and were negative (upper left corner) then the patient should be treated with a daily proton pump inhibitor (PPI). If symptoms (Sx) do not improve after 4–8 weeks, a therapeutic trial with a TCA should be initiated (the percentage of patients with FD symptom resolution is shown in parentheses). If upper endoscopy is grossly normal but gastric biopsies were not obtained for H. pylori, then the algorithm should begin with an assessment of H. pylori prevalence (upper right side). If present, H. pylori should be treated and the occasional patient with H. pylori will experience FD symptom resolution. If the patient is H. pylori-negative, then PPI therapy should be initiated (upper middle of diagram). The percentage of H. pylori-negative FD patients previously treated with a PPI and then a TCA, who will improve with an anti-nociceptive agent or CAM, is unknown. Therapeutic Gain (T.G.) refers to the reported symptom improvement rate above the placebo response (i.e. not including the placebo response). The overall Response Rate (R. R.) refers to the overall response rate which includes the placebo response. For example, on the right hand side of the diagram, the therapeutic gain (T.G.) of treating an FD patient who is H.P (+) has been reported as 6–14%. Alternatively, this portion of the figure could have been labelled using the overall response rate (R.R.) for FD symptom improvement in a patient treated for HP, which is approximately 31–39%, as this includes the placebo response rate which is approximately 25%.