Dyspepsia Treatment

Clinical Decision

• Patients <40 years old (depending on local protocol) without alarm features and prior dyspepsia workup can be treated either by:
  
  • Empiric therapy with antisecretory agents if local H pylori prevalence is <5%
  • Testing and, if positive, treating for H pylori if local prevalence is >10%
  • If local prevalence rate is 5-10%, treatment choice will depend on length of symptoms, comorbidities, NSAID use, risk factors for gastric or esophageal malignancy, testing availability and cost, and patient preference
  • The 2017 American College of Gastroenterology and Canadian Association of Gastroenterology guideline on dyspepsia recommend that patients <60 years old have non-invasive testing and, if positive, treatment for H pylori

• H pylori testing and treating are effective as initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia
  
  • Recommended as initial therapy by some experts

Therapeutic Principles for Empiric Therapy 

• Acid suppression, given for 4-8 weeks, is the recommended initial therapy
  • Patients should be treated with a 4-week trial of acid suppression before deciding whether or not therapy has been effective
• It is not clear which class of drugs (PPIs, H₂RAs or prokinetic agents) would be the most appropriate for all patients
  • May consider prescribing based on predominant symptom complaints
• In areas where H pylori infection is prevalent, empiric therapy is not recommended in H pylori-positive patients with dyspepsia

Proton Pump Inhibitors (PPIs)

• PPIs were shown to be more effective than other agents as initial therapeutic strategy at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia when patients were not adequately excluded for GERD
• Preferred acid suppression for H pylori-negative patients or those who continue to be symptomatic despite H pylori eradication therapy
• Patients with heartburn symptoms may be treated initially with PPI then step-down therapy with low-dose PPIs or H₂RAs once their symptoms improve

Histamine₂-Receptor Antagonists (H₂RAs)

• Individual patients may respond to H₂RA therapy
  • H₂RAs have been shown to be significantly more effective than placebo
• May be given to patients who had inadequate response to PPI therapy 
• H₂RAs may also be used as step-down therapy

Prokinetic Agents

• Individual patients, often those with dysmotility-like symptoms, may respond to prokinetics
• Treatment should be at the lowest effective dose for the shortest duration possible to reduce the risk of adverse effects
  • Studies show that Mosapride does not have any significant cardiovascular effects even with concomitant administration of Ketoconazole and Erythromycin; Mosapride does not block D2 receptor hence does not cause extrapyramidal effects   

Adjunctive Therapy

Antacids and Gastroprotective Agents

• Self-treatment with antacid with or without alginates may be continued for immediate symptom relief but additional therapy is appropriate to manage persistent or more severe symptoms
• Antacids, alginates and gastroprotective agents (eg Rebamipide, Sucralfate) effectively reduce acid and improve symptoms but evidence of healing effect has not been demonstrated

Antidepressants and Anxiolytics 

• Efficacy in the treatment of functional dyspepsia was shown in two meta-analyses
• Tricyclic antidepressants (TCAs) may be used as 2nd-line therapy (if appropriate) in patients with functional dyspepsia if dyspeptic symptoms failed to improve with initial PPI or H pylori eradication therapy; if unresponsive to TCAs, offer treatment with prokinetic agents

• To reduce anxiety in cases where there are no indications of organic disease, reassurance is an important part of initial therapy
• Provide patients with access to educational materials to support the care they receive and emphasize adherence to medical therapy 
• Patients with refractory functional dyspepsia have a high rate of accompanying depression and psychiatric illness
  • May consider psychological therapies, eg cognitive behavioral therapy (CBT) and psychotherapy, or antidepressants to reduce dyspeptic symptoms especially in non-ulcer dyspepsia