British Society of Gastroenterology guidelines on the management of functional dyspepsia

Abstract

Functional dyspepsia (FD) is a common disorder of gut-brain interaction, affecting approximately 7% of individuals in the community, with most patients managed in primary care. The last British Society of Gastroenterology (BSG) guideline for the management of dyspepsia was published in 1996. In the interim, substantial advances have been made in understanding the complex pathophysiology of FD, and there has been a considerable amount of new evidence published concerning its diagnosis and classification, with the advent of the Rome IV criteria, and management. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based diagnosis and treatment of patients. The approach to investigating the patient presenting with dyspepsia is discussed, and efficacy of drugs in FD summarised based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of pairwise and network meta-analyses. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system. These provide both the strength of the recommendations and the overall quality of evidence. Finally, in this guideline, we consider novel treatments that are in development, as well as highlighting areas of unmet need and priorities for future research.

Keywords: functional dyspepsia; meta-analysis.

Figure 1

Diagnostic algorithm for functional dyspepsia. DGBI, disorder of gut–brain interaction; FD, functional dyspepsia.

Figure 2

Treatment algorithm for functional dyspepsia. *Successful eradication of H. pylori should only be confirmed in those with an increased risk of gastric cancer. +Triggers may include spicy food or alcohol, for example, but there is insufficient evidence to recommend specific dietary therapies, including a diet low in fermentable oligosaccharides, di- and monosaccharides, and polyols in FD. †Overall, there is insufficient evidence to make recommendations regarding whether any treatment should be preferred in patients with EPS or PDS. ‡Efficacy of prokinetics varies according to drug class, and many of these drugs are unavailable outside of Asia and the USA. Most trials of acotiamide have been conducted in patients with PDS. §There is no evidence that selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors, used as gut–brain neuromodulators, are an efficacious treatment for FD. ∞Tricyclic antidepressants should be used as a first-choice gut–brain neuromodulator. They can be initiated in primary or secondary care, starting at a dose of 10 mg at night, and titrating slowly (eg, by 10 mg per week) according to response and tolerability. Continue for at least 6–12 months if the patient reports a symptomatic benefit. ⁑Mirtazapine may be useful in patients with FD and early satiation and weight loss. EPS, epigastric pain syndrome; FD, functional dyspepsia; PDS, postprandial distress syndrome.