Meta-analysis of antisecretory and gastrokinetic compounds in functional dyspepsia

Famotidine in the treatment of functional dyspepsia: a randomized double-blind, placebo-controlled trial

AIM

In the present study, we aimed to investigate patients with a documented diagnosis of functional dyspepsia (FD) who had been admitted to our outpatient Gastroenterology Clinic and provided consent to participate in this randomized, double-blind, placebo-controlled trial of the therapeutic impact of famotidine on the symptoms and quality of life of FD patients.

PARTICIPANTS AND METHODS

A total of 160 patients attending our outpatient clinic with a diagnosis of FD according to Rome III criteria were enrolled in this double-blind study. They were randomized into case (famotidine treatment) and placebo groups; patients were asked to refill the Honk Kong dyspepsia index (a self global assessment tool) before the start of the study as well as after 3 months of treatment.

RESULTS

Both famotidine and placebo led to significant improvements in dyspepsia symptoms, except for vomiting in both groups and loss of appetite in the placebo control group. However, the extent of these improvements was not different between the two study groups for most of the study parameters, whereas belching, feeling of acid regurgitation, heartburn, and the total score for the Hong Kong dyspepsia index were significantly more responsive to famotidine than placebo. No significant effectiveness of famotidine therapy was found regarding quality of life.

CONCLUSION AND RECOMMENDATIONS

This study showed a significant improvement in the total dyspepsia scores of FD, with a marked effect on belching, heartburn, and the feeling of acid regurgitation. These findings suggest that famotidine may be administered in certain FD patients who have significantly more symptoms of belching, heartburn, and acid regurgitation.

Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia

BACKGROUND

Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel.

METHODS

We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence.

CONCLUSION

Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.

Prospective multi-center trial for the efficacy of ecabet sodium on the relief of dyspepsia in korean patients with chronic gastritis

Anti-peptic and anti-inflammatory actions of ecabet sodium might be beneficial in either improving gastritis or relieving dyspeptic symptoms. This study was designed to evaluate the clinical efficacy of ecabet sodium on dyspeptic symptoms and to elucidate the molecular mechanism attributable to symptom relief in patients with chronic gastritis. Two hundred and sixty eight chronic gastritis patients with persistent dyspepsia received ecabet sodium 1 g b.i.d. for 2 weeks, after which dyspeptic symptoms were reassessed with a questionnaires as before. The changes of interleukin-8 (IL-8), inducible nitric oxide synthase (iNOS), prostaglandin E(2) (PGE(2)), and vascular endothelial growth factor (VEGF) levels in gastric juices were measured by ELISA. The changes of nitrotyrosine in gastric mucosa were measured by immunohistochemical staining. The most common dyspeptic symptom in Korean patients with chronic gastritis was epigastric soreness (76.8%), which was improved significantly after ecabet sodium treatment (81.7%, p<0.001). Ecabet sodium was more effective in patients with epigastric pain than vague abdominal discomfort (p = 0.02), especially in patients with old age. Complete relief of discomfort was more highly achieved in patients with positive Helicobacter pylori than without (p = 0.01). In spite of clear tendency that the decreased levels of IL-8, iNOS, and PGE(2) and increased levels of VEGF were measured in gastric juices after ecabet sodium treatment, no statistical significance was noted, which might be due to high inter-individual variations. The nitrotyrosine expressions were significantly decreased after ecabet sodium treatment than before (p<0.01). In conclusion, ecabet sodium treatment was very useful for the relief of dyspeptic symptoms in chronic gastritis, to which both attenuated inflammatory and enhanced regenerative mechanisms were contributive.

Review article: endpoints used in functional dyspepsia drug therapy trials

BACKGROUND

The measurement of patient-reported outcomes (PRO) in treatment trials for functional gastrointestinal disorders is a matter of controversy.

AIM

To focus on instruments and endpoints that have been used to evaluate the efficacy of therapeutic agents in functional dyspepsia (FD) trials, also considering the newly defined Rome III FD criteria.

METHODS

A Medline search was conducted to identify relevant studies pertaining to FD treatment, with particular emphasis on the studies to date which have used validated outcome measures.

RESULTS

Currently available outcome measures are heterogeneous across studies. They include global binary endpoints, analogue or categorical scoring scales, uni- or multi-dimensional disease specific questionnaires, global outcome evaluations and quality of life questionnaires. Across the available outcome measures, substantial heterogeneity is found, not only in the type of endpoint measure, but also in the number and types of symptoms that are considered to be part of the FD symptom complex. Especially based on content validity, none of the existing questionnaires or endpoints can be considered sufficiently validated to be recommended unequivocally as the primary outcome measure for FD trials according to the Rome III criteria. On the other hand, existing well-validated multi-dimensional questionnaires that include many non-FD symptoms can be narrowed down to evaluate only the cardinal symptoms according to Rome III.

CONCLUSIONS

There is an urgent need to develop Rome III-based patient-reported outcomes for functional dyspepsia. Well-validated multi-dimensional questionnaires may serve as a guidance for this purpose, and could also be considered for use in ongoing clinical trials.

Ecabet sodium induces neuronal nitric oxide synthase-derived nitric oxide synthesis and gastric adaptive relaxation in the human stomach

BACKGROUND

Gastric adaptive relaxation (GAR) is a major factor of functional dyspepsia (FD). Nitric oxide (NO) could be the key molecule responsible for GAR. We previously reported that the physiological gastric reservoir ability can be evaluated by measuring the cross-sectional area of the proximal stomach by abdominal ultrasonography (US). Ecabet sodium (ES), a gastro-protective antiulcer agent, has been shown to improve symptoms in FD patients. We examined the effects of ES on GAR in humans and on NO synthesis in vitro.

METHODS

GAR was measured by US in 14 subjects, 8 of whom had a pressure sensor inserted into their stomach, after treatment with ES, placebo, or no drugs. NO was measured in SH-SY 5Y cells using a fluorescent indicator. Neuronal, endothelial and inducible NO synthase (nNOS, eNOS and iNOS, respectively) expressions were examined in SH-SY 5Y cells by Western blotting.

RESULTS

Compared to placebo, ES induced significantly greater dilatation of the proximal stomach after the subjects drank 300-400 ml water (P < 0.05). After ES intake, the intragastric pressure did not change significantly, but it tended to be lower (n = 8; P = 0.15). ES increased NO production and nNOS expression, but not iNOS or eNOS expression, in SH-SY 5Y cells in vitro. Pretreatment with non-selective NO synthase (NOS) inhibitor, but not with iNOS-selective inhibitor, reduced NO production by ES.

CONCLUSION

ES may promote GAR in humans through nNOS-related NO; therefore, it may be useful for patients with FD.

Gastroparesis: current concepts and management

Delayed gastric emptying in the absence of mechanical obstruction is referred to as gastroparesis. Symptoms that are often attributed to gastroparesis include postprandial fullness, nausea, and vomiting. Although tests of gastric motor function may aid diagnostic labeling, their contribution to determining the treatment approach is often limited. Although clinical suspicion of gastroparesis warrants the exclusion of mechanical causes and serum electrolyte imbalances, followed by empirical treatment with a gastroprokinetic such as domperidone or metoclopramide, evidence that these drugs are effective for patients with gastroparesis is far from overwhelming. In refractory cases with severe weight loss, invasive therapeutics such as inserting a feeding jejunostomy tube, intrapyloric injection of botulinum toxin, surgical (partial) gastrectomy, and implantable gastric electrical stimulation are occasionally considered.

Efficacy of the natural antioxidant astaxanthin in the treatment of functional dyspepsia in patients with or without Helicobacter pylori infection: A prospective, randomized, double blind, and placebo-controlled study

OBJECTIVES

The aim of this study was to evaluate the efficacy of the natural antioxidant astaxanthin in functional dyspepsia in different doses and compared with placebo.

DESIGN

The study was a controlled, prospective, randomized, and double blind trial.

PARTICIPANTS

Patients with functional dyspepsia, divided into three groups with 44 individuals in each group (placebo, 16mg, or 40mg astaxanthin, respectively).

INTERVENTIONS

Participants were asked to accept gastroscopy before treatment, together with questionnaires: GSRS and SF-36. Urea breath test (UBT) was done before the treatment.

MAIN OUTCOME

The primary objective was to test the hypothesis that the antioxidant astaxanthin at two doses regimens compared to placebo should ameliorate gastrointestinal discomfort measured as GSRS in patients with functional dyspepsia, who were either positive or negative for Helicobacter pylori, after 4 weeks of treatment.

RESULTS

At the end of therapy (week 4) no difference between the three treatment groups was observed regarding mean Gastrointestinal Symptom Rating Scale (GSRS) scores of abdominal pain, indigestion and reflux syndromes. The same results were observed at the end of follow-up. However reduction of reflux syndrome before treatment to week 4 was significantly pronounced in the higher (40mg) dose compared to the other treatment groups (16mg and placebo, p=0.04).

CONCLUSION

In general, no curative effect of astaxanthin was found in functional dyspepsia patients. Significantly greater reduction of reflux symptoms were detected in patients treated with the highest dose of the natural antioxidant astaxanthin. The response was more pronounced in H. pylori-infected patients.

Clinical trial: effects of tegaserod on gastric motor and sensory function in patients with functional dyspepsia

BACKGROUND Tegaserod, a serotonin receptor type-4 partial agonist, stimulates gastrointestinal motility and has been shown to increase gastric volumes before and after a meal in healthy volunteers. Its effect on gastric motor and sensory function in patients with functional dyspepsia is unclear. AIM To evaluate the effects of tegaserod on gastric compliance, accommodation and gastric sensory function in patients with functional dyspepsia and healthy volunteers. METHODS Sixteen patients with functional dyspepsia and 12 healthy volunteers were studied on two occasions, each after a 7-day treatment with either placebo or tegaserod 6 mg b.d. using a double-blind, randomized, crossover design. After each treatment period a gastric barostat study was performed fasting and during intraduodenal lipid infusion. RESULTS Tegaserod increased postprandial gastric compliance in functional dyspepsia patients (P = 0.04). Healthy volunteers showed enhanced postprandial gastric compliance after placebo (P = 0.03). Between-treatment analysis of gastric accommodation revealed a significant increase in intrabag volumes after tegaserod in healthy volunteer (P = 0.04); no difference could be seen in functional dyspepsia patients. Tegaserod had no effect on gastric sensation. CONCLUSIONS Tegaserod enhances postprandial gastric compliance in functional dyspepsia patients and gastric accommodation in healthy volunteers. The improvement of proximal gastric motor function suggests a beneficial role of tegaserod in patients with functional dyspepsia.

Treatment of functional dyspepsia with serotonin agonists: a meta-analysis of randomized controlled trials

BACKGROUND

Functional dyspepsia (FD) is often treated with serotonin agonists; however, the efficacy of such agents has recently been questioned. The aim of this study was to perform a meta-analysis of randomized controlled trials (RCTs) comparing serotonin agonists with other types of prokinetics in patients with FD.

METHODS

Included studies were RCTs that compared serotonin agonists, including cisapride and mosapride, with dopamine antagonists, including metoclopramide and domperidone, and an opiate agonist, trimebutine, in patients with FD. Studies were identified by searching the Medline database (January 1951 - January 2005) and Cochrane Library (Issue 4, 2004), and by manual searches. The difference in the probability of patients' responses between the serotonin agonists and control agents was used as a summary statistic for the treatment effect. Meta-regression analysis was used to detect sources of heterogeneity.

RESULTS

Five studies were identified. In total, 467 subjects were assigned to a serotonin agonist arm, and 322 subjects were assigned to a control arm. In the overall analysis, the summary statistic was 0.019 (95% confidence interval [CI]: -0.055 to 0.093; P = 0.612), indicating that the patients' responses to serotonin agonists were similar to those to control agents. However, in the stratified meta-analysis of cisapride and mosapride, mosapride had a 6.7% greater probability of producing a response compared with control agents (summary statistic: 0.067; 95% CI: 0.010-0.124; P = 0.021), whereas no significant effect was observed with cisapride.

CONCLUSION

The data suggest that mosapride may be more effective than cisapride for the treatment of FD. Although FD is a chronic condition, efficacy was assessed over short periods in the studies used for the present meta-analysis. Long-term RCTs are needed to confirm the effect.

The difficult patient with gastroparesis

Gastroparesis is often difficult to manage. First of all, exact criteria for making a diagnosis of gastroparesis have not been established, and merely finding delayed gastric emptying does not justify the label. Furthermore, the relationship between symptoms and gastric emptying rate is poor, and the number of therapies with proven efficacy is extremely limited. A number of technical investigations are helpful to establish the anatomy and motor function of the upper gastrointestinal tract. In most cases where gastroparesis can be presumed or established, prokinetic therapy will be tried. A number of agents are available, with variable efficacy and tolerance. Rarely, in case of debilitating refractory symptoms, experimental or invasive therapies can be tried such as injection of botulinum toxin, enteral feeding tube insertion, gastric electrical stimulation or surgery.

Therapeutic effect of melatonin in patients with functional dyspepsia

BACKGROUND AND GOAL

Melatonin may inhibit reactive oxygen species-related pathogenesis in the alimentary tract by neutralizing free radicals. In the present study we assessed the potential protective action of melatonin in ulcerlike dyspepsia.

STUDY

Sixty patients aged 19 to 39 years with the diagnosis of functional dyspepsia according to the Rome Criteria II and no Helicobacter pylori infection were involved in the study. Melatonin, at a dose of 5 mg (n=30), or placebo (n=30) were taken in the evening for a period of 12 weeks. At this time, patients were on an equivalent diet and were only to take an alkaline drug in case of the abdominal pain.

RESULTS

After 12 weeks, the dyspeptic symptoms completely subsided in 17 patients in the melatonin-treatment group (56.6%). In other 9 individuals (30.0%) a partial improvement in health was achieved, especially in the frequency and intensity of nocturnal pain. After placebo, the majority of patients (93.3%) did not experience any improvement in symptoms. Multivariate analysis indicated that melatonin (odds ratio 95.86, 95% confidence interval 3.72-2469.37, P<0.01) correlated independently with significantly improved patients health. H. pylori past infection decreased positive effect of melatonin in ulcerlike dyspepsia.

CONCLUSIONS

Melatonin can be considered as an auxiliary drug in the treatment of ulcerlike dyspepsia.

Meta-analysis of the effects of prokinetic agents in patients with functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is often treated with prokinetic agents; however, the efficacy of prokinetic agents in patients with FD has been questioned recently. The aim of this study was to perform a meta-analysis of the effects of prokinetic agents in patients with FD.

METHODS

Prokinetic agents, including metoclopramide, domperidone, trimebutine, cisapride, itopride and mosapride, used for treatment of FD between 1951 and 2005 were identified. Twenty-seven studies were selected. Difference in the probability of response between the interventional drug and placebo was used as a summary statistic for the treatment effect. Meta-regression analysis was used to detect sources of heterogeneity.

RESULTS

In total, 1844 subjects were assigned to an experimental arm, and 1591 subjects were assigned to a placebo arm. Publication bias was ruled out by funnel plot and statistical testing (P = 0.975). In the overall analysis, the summary statistic was 0.295 (95% confidence interval: 0.208-0.382, P < 0.001), indicating that the interventional drug has 30% excess probability of producing a response compared with placebo. The most significant source of heterogeneity was the year of publication (P < 0.001).

CONCLUSION

The data clearly indicate that prokinetic agents are significantly more effective than placebo in the treatment of FD. Although FD is a chronic condition, efficacy was assessed over short periods. Long-term randomized controlled trials are needed to confirm the effect.

Effects of proton-pump inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials

BACKGROUND & AIMS

The aim of this study was to assess systematically the efficacy of proton pump inhibitors (PPIs) in the treatment of functional dyspepsia compared with placebo and to determine if any difference in the response exists between symptom subgroups of functional dyspepsia.

METHODS

A literature search was performed through September 2005 in PubMed, Medline, Embase, CINAHL, and Cochrane databases to include randomized, double-blind, placebo-controlled trials evaluating the efficacy of PPIs for the treatment of functional dyspepsia. Relative risk (RR) and relative risk reduction (RRR) and 95% confidence intervals (CI) were calculated under a random-effects model.

RESULTS

Seven studies with a total of 3725 patients were identified. PPIs were found to be more effective than placebo for reducing symptoms in patients with functional dyspepsia (RRR, 10.3%; 95% CI, 2.7%-17.3%). The estimated number needed to treat is 14.6 (95% CI, 8.7-57.1). When stratified analyses were performed, a significant difference in the efficacy was observed only in patients with ulcer-like (RRR, 12.8%; 95% CI, 7.2%-18.1%) and reflux-like dyspepsia (RRR, 19.7%; 95% CI, 1.8%-34.3%), but not in those with dysmotility-like (RRR, 5.1%; 95% CI, -10.9% to 18.7%) and unspecified dyspepsia (RRR, -8.0%; 95% CI, -23.7% to 5.6%). The effect of H pylori on the efficacy of PPIs remains unclear. Significant heterogeneity among studies was found for the overall analysis, dysmotility-like dyspepsia, H pylori-negative subgroup, and different dose subgroups.

CONCLUSIONS

PPIs are more effective than placebo for the management of patients with ulcer-like and reflux-like functional dyspepsia.

Quality of life in patients with functional dyspepsia: Short- and long-term effect of Helicobacter pylori eradication with pantoprazole, amoxicillin, and clarithromycin or cisapride therapy: A prospective, parallel-group study

BACKGROUND

Quality of life (QOL) is impaired in functional dyspepsia (FD). Little is known about the effects of different therapies on the QOL profile in patients with this condition.

OBJECTIVES

The aims of this study were to measure baseline QOL in patients with FD and to assess changes in QOL over time associated with Helicobacter pylori eradication and prokinetic treatment. The primary and secondary end points were the improvement in QOL 6 weeks and 1 year after successful eradication of the infection or prokinetic therapy.

METHODS

This 1-year, single-center, prospective, open-label, controlled, parallel-group trial was conducted at the Department of Gastroenterology, Ferencvdros Health Centre, Budapest, Hungary. The Functional Digestive Disorder Quality of Life (FDDQoL) Questionnaire (MAPI Research Institute, Lyon, France) was translated and validated previously in Hungarian. Male and female subjects aged 20 to 60 years were enrolled and classified as H pylori positive (HP+), H pylori negative (HP-) with FD, or healthy (control group). The HP+ patients received pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID for 7 days, followed by on-demand ranitidine (150-300 mg/d) for 1 year. The HP- patients received the prokinetic cisapride 10 mg TID for 1 month, followed by on-demand cisapride (10-20 mg/d) for 1 year. The FDDQoL questionnaire was completed by all 3 groups on enrollment, at 6 weeks, and 1 year.

RESULTS

A total of 101 HP+ patients, 98 HP- patients, and 123 healthy controls were included in the study (185 women, 137 men; mean age, 39.0 ears). The mean (SD) baseline QOL scores were significantly lower in the HP+ group (53.3 [9.6]; 95% CI, 54.4-58.2) and the HP- groups (50.0 [9.8]; 95% CI, 58.0-62.0) compared with that in healthy controls (76.2 [8.7]; 95% CI, 74.6-77.8) (both, P < 0.001). Analysis of the short-term domain scores found that the HP+ group had significantly decreased scores in 6 of 8 domains: daily activities (P = 0.005), anxiety level (P = 0.02), diet (P = 0.008), sleep (P < 0.001), discomfort (P = 0.004), and disease control (P = 0.02); the HP- group had significantly decreased scores in 5 of 8 domains: daily activities (P < 0.001), diet (P = 0.004), sleep (P = 0.005), discomfort (P < 0.001), and disease control (P = 0.02). Eradication of the infection was successful in 77/101 (76.2%) of the patients on intent-to-treat analysis and 77/94 (81.9%) on per-protocol analysis. Eradication was associated with an increase in mean (SD) QOL score to 70.8 (10.7) at 6 weeks (95% CI, 63.3-73.2; P < 0.001 vs baseline) and to 75.3 (9.3) at 1 year (95% CI, 73.2-77.5; P= 0.05 vs 6 weeks). In the HP- group, the QOL score increased to 73.3 (9.7) (95% CI, 71.3-75.4; P < 0.001 vs baseline) at 6 weeks of cisapride treatment and to 76.5 (8.5) at 1 year (95% CI, 74.5-78.4; P = 0.06 vs 6 weeks). Most of the impaired domain scores improved significantly after both treatments. The short-term effect size was 1.48 in HP+ and 1.35 in HP- patients. Adverse events (AEs) occurred in 22 (21.8%) patients in the HP+ group (nausea, 8 [7.9%] patients; diarrhea, 5 [5.0%]; loss of appetite, 5 [5.0%]; stomatitis, 5 [5.0%]; abdominal pain, 4 [4.0%]; bloating, 4 [4.0%]; headache, 4 [4.0%]; vomiting, 4 [4.0%]; constipation, 3 [3.0%]; and vaginitis, 3 [3.0%]). In HP- cases, AEs occurred in 9 (9.2%) patients (abdominal cramps, 7 [7.1%]; diarrhea, 4 [4.1%]; and nausea, 3 [3.1%]).

CONCLUSION

In this study in patients with FD and healthy controls, eradication of H pylori infection in infected patients and cisapride treatment in uninfected patients reversed low QOL scores during the 1-year follow-up period.

Comparison between empirical prokinetics, Helicobacter test-and-treat and empirical endoscopy in primary-care patients presenting with dyspepsia: A one-year study

AIM: To investigate the optimal strategy to treat dyspeptic patients in primary care.

METHODS: Dyspeptic patients presenting to primary care outpatient clinics were randomly assigned to: (1) empirical endoscopy, (2) H pylori test-and-treat, and (3) empirical prokinetic treatment with cisapride. Early endoscopy was arranged if patients remained symptomatic after 2 wk. Symptom severity, quality-of-life (SF-36) as well as patient preference and satisfaction were assessed. All patients underwent endoscopy by wk 6. Patients were followed up for one year.

RESULTS: Two hundred and thirty four patients were recruited (163 female, mean age 49). 46% were H pylori positive. 26% of H pylori tested and 25% of empirical prokinetic patients showed no improvement at wk 2 follow-up and needed early endoscopy. 15% of patients receiving empirical cisapride responded well to treatment but peptic ulcer was the final diagnosis. Symptom resolution and quality-of-life were similar among the groups. Costs for the three strategies were HK$4343, $1771 and $1750 per patient. 66% of the patients preferred to have early endoscopy.

CONCLUSION: The three strategies are equally effective. Empirical prokinetic treatment was the least expensive but peptic ulcers may be missed with this treatment. The H pylori test-and-treat was the most cost-effective option.

Influence of intrapyloric botulinum toxin injection on gastric emptying and meal-related symptoms in gastroparesis patients

BACKGROUND

Recent observations in limited numbers of patients suggest a potential benefit of intrapyloric injection of botulinum toxin in the treatment of gastroparesis.

AIM

To characterize the effect of botulinum toxin on solid and liquid gastric emptying and on meal-related symptoms.

METHODS

In 20 gastroparesis patients (17 women, mean age 37 +/- 3 years, three diabetic and 17 idiopathic), gastric emptying for solids and liquids was measured before and one month after intrapyloric botulinum toxin 4 x 25 units. Before the meal and at 15-min intervals up to 240 min postprandially, the patient graded the intensity of six gastroparesis symptoms, and a meal-related severity score was obtained by adding all intensities. Data (mean +/- S.E.M.) were compared using paired Student's t-test.

RESULTS

Treatment with botulinum toxin significantly enhanced solid (t(1/2) 132 +/- 16 vs. 204 +/- 35 min, P < 0.05) but not liquid (92 +/- 10 vs. 104 +/- 11 min, N.S.) emptying. This was accompanied by a significant decrease in cumulative meal-related symptom score (73.5 +/- 16.3 vs. 103 +/- 17.1 baseline, P = 0.01) as well as individual severity scores for postprandial fullness, bloating, nausea and belching (all P < 0.001, two-way anova).

CONCLUSIONS

Botulinum toxin improves solid but not liquid gastric emptying in gastroparesis, and this is accompanied by significant improvement of several meal-related symptoms.

Therapeutic strategies for functional dyspepsia and the introduction of the Rome III classification

Although placebo response rates in clinical trials for functional dyspepsia (FD) are more than 30%, a recent meta-analysis based on randomized controlled trials (RCTs) showed that antisecretory drugs were more or less superior to placebos. On the other hand, large-scale RCTs on the efficacy of treatment with prokinetics on FD are still needed. Indications for antibiotic eradication therapy for Helicobacter pylori-positive FD are still controversial, but there seems to be a small but significant therapeutic gain achieved with H. pylori eradication. Since preprandial and postprandial symptomatic disturbances are very important targets for FD treatment, ghrelin, a novel appetite-promoting gastrointestinal peptide that also promotes gastric motility or basal acid secretion can be expected to be a therapeutic target. In the recently published Rome III classification, FD is redefined for patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation, and it is divided into the subcategories postprandial distress syndrome and epigastric pain syndrome. These new criteria are of value in clinical practice, for epidemiological, pathophysiological, and clinical research, and for the development of new therapeutic strategies.

Drug treatment of functional dyspepsia

Symptomatic improvement of patients with functional dyspepsia after drug therapy is often incomplete and obtained in not more than 60% of patients. This is likely because functional dyspepsia is a heterogeneous disease. Although great advance has been achieved with the consensus definitions of the Rome I and II criteria, there are still some aspects about the definition of functional dyspepsia that require clarification. The Rome criteria explicitly recognise that epigastric pain or discomfort must be the predominant complaint in patients labelled as suffering from functional dyspepsia. However, this strict definition can create problems in the daily primary care clinical practice, where the patient with functional dyspepsia presents with multiple symptoms. Before starting drug therapy it is recommended to provide the patient with an explanation of the disease process and reassurance. A thorough physical examination and judicious use of laboratory data and endoscopy are also indicated. In general, the approach to treat patients with functional dyspepsia based on their main symptom is practical and effective. Generally, patients should be treated with acid suppressive therapy using proton-pump inhibitors if the predominant symptoms are epigastric pain or gastroesophageal reflux symptoms. Although the role of Helicobacter pylori (H pylori) in functional dyspepsia continues to be a matter of debate, recent data indicate that there is modest but clear benefit of eradication of H pylori in patients with functional dyspepsia. In addition, H pylori is a gastric carcinogen and if found it should be eliminated. Although there are no specific diets for patients with FD, it may be helpful to guide the patients on healthy exercise and eating habits.

Promotility medications--now and in the future

Gastrointestinal promotility drugs stimulate smooth muscle contractions to enhance gastric emptying and small and large bowel transit. Currently available drug classes with prokinetic properties include antidopaminergic agents, serotonergic agents, and motilin-receptor agonists. Due to moderate prokinetic effects, poor symptomatic responses and the presence of adverse effects, there is a clear need for new classes of prokinetics. Several newer prokinetic drugs and drug classes are currently under evaluation. Selecting candidate agents and designing the appropriate therapeutic trials is hampered by the lack of insight in the pathophysiology of motility-related symptoms. As gastrointestinal motor disorders are chronic, relapsing, and remitting disorders, it seems desirable that studies with candidate prokinetic drugs establish a long-term efficacy and not only short-term effects on gastrointestinal functions.

Usefulness of famotidine in functional dyspepsia patient treatment: comparison among prokinetic, acid suppression and antianxiety therapies

BACKGROUND

The treatment of functional dyspepsia is controversial.

AIM

The purpose of this paper is to clarify the initial effect of prokinetic, acid suppression and antianxiety treatment for functional dyspepsia patients.

PATIENTS AND METHODS

Sixty-four functional dyspepsia patients without Helicobacter pylori infection were randomly assigned to 15 mg/day of mosapride, 40 mg/day of famotidine, or 30 mg/day of tandospirone during an 8-week treatment. Individual functional dyspepsia symptoms were evaluated with 4 cm visual analogue scale before and at 2, 4 and 8 weeks after treatment.

RESULTS

Among 64 enrolled patients, 62 completed the study. Within 2 weeks, visual analogue scale score in the mosapride-treated group decreased from 2.29 +/-0.14 to 1.57 +/- 0.20; in the famotidine from 2.04 +/- 0.16 to 1.09 +/- 0.12 (mean +/- S.E.). Therefore, there were significant improvements of functional dyspepsia symptoms in mosapride- and famotidine-treated patients (P <0.01). Furthermore, famotidine was significantly more effective than mosapride (P < 0.05). On the contrary, visual analogue scale score in the tandospirone therapy was 2.23 +/- 0.20 and 2.13 +/- 0.22 before and at 2 weeks, respectively, without any significant improvement.

CONCLUSIONS

A treatment regimen of famotidine at 40 mg/day had a significant favourable effect on the clinical outcome in functional dyspepsia patients.

Randomized, double-blind, placebo-controlled crossover trial of famotidine in patients with functional dyspepsia

BACKGROUND

Histamine 2-receptor antagonists were used as a first therapy against functional dyspepsia. However, few clinical studies with famotidine for functional dyspepsia have been reported.

AIM

To evaluate the effectiveness of famotidine for functional dyspepsia patients.

METHODS

A multicentre, randomized, double-blind, placebo-controlled crossover trail was conducted. Patients diagnosed with functional dyspepsia by the Roma II criteria were included. Subjects were randomized into two groups, and received either famotidine or placebo as the first 4 weeks medication. After a 1-week washout period, they were switched to the other regimen for another 4 weeks. Evaluation was made prior to the start of study, upon completion of the first drug cycle, and the second drug cycle, by Gastrointestinal Symptoms Rating Scale for the seriousness of abdominal symptoms, and by Short Form-36 for the level of quality of life.

RESULTS

Nineteen of 21 enrolled patients successfully completed this study. Significant improvement in Gastrointestinal Symptoms Rating Scale scores was observed in abdominal pain (P = 0.007), indigestion and reflux syndrome after famotidine treatment. Also quality of life scores showed significant improvement in body pain, vitality and general health perceptions after famotidine treatment. There was no improvement of symptoms and quality of life scores after administration of placebo.

CONCLUSIONS

Famotidine was effective for improving symptoms and quality of life in functional dyspepsia patients.

Pathophysiology and treatment of functional dyspepsia

Functional dyspepsia is a highly prevalent symptom complex and a heterogenous disorder. Recent studies showed potential associations between specific pathophysiologic disturbances and dyspeptic symptoms. Delayed gastric emptying reported in about 30% of patients with functional dyspepsia is associated with the symptoms of postprandial fullness, nausea, and vomiting. Impaired gastric accommodation present in 40% of functional dyspepsia patients is found to be associated with early satiety. Hypersensitivity to gastric distension is observed in 37% of functional dyspepsia patients and associated with the symptoms of postprandial pain, belching, and weight loss. Psychosocial factors and altered response to duodenal lipids or acid have also been identified as pathophysiologic mechanisms. Therapeutic options are still limited but targeted therapy directed at the underlying pathophysiology seems desirable. Thus, efforts to further elucidate underlying pathophysiologic mechanisms and identify the appropriate patient population using some type of pathophysiologic testing will be required.

Idiopathic dyspepsia

Idiopathic dyspepsia refers to pain and/or discomfort perceived in the epigastrium that is not secondary to organic, systemic, or metabolic diseases. Symptoms may overlap with those of gastroesophageal reflux disease and irritable bowel syndrome. Gastrointestinal motor disorders, hypersensitivity to mechanical or chemical stimuli, and psychosocial factors can act individually or in concert to induce the symptoms of dyspepsia. Accordingly, there is no single therapy, and treatment must be individualized. Eradication of Helicobacter pylori infection rarely achieves symptom improvement. Treatment of idiopathic dyspepsia should begin by reassuring the patient about the benign nature of the syndrome and educating them on the knowledge that has been achieved in recent years regarding potential causes of the syndrome. Both prokinetic and antisecretory drugs have been reported to improve dyspeptic symptoms, but results are not completely convincing. Although well-designed studies demonstrate superiority of proton pump inhibitors over placebo, it should be noted that patients with nonerosive gastroesophageal reflux disease were invariably included; when these patients are excluded, the benefit of antisecretory medications is questionable. We suggest that patients with idiopathic dyspepsia be initially treated according to the predominant symptom. Those with epigastric pain/burning should receive a trial with standard doses of proton pump inhibitors for 4 to 8 weeks, whereas prokinetic patients should be prescribed at recommended doses for similar periods of time to patients with nonpainful dyspeptic symptoms such as posprandial fullness, early satiety, nausea, or vomiting. Nonresponders may benefit from combination therapies or short trials with higher doses of drugs. Visceral analgesics and antidepressants can also be prescribed alone or in combinations with other therapeutic strategies. Recent studies demonstrate utility for psychologic therapy and hypnotherapy, although truly controlled studies are difficult in this area. Herbal medicines deserve further evaluation.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

Identifying response to acid suppressive therapy in functional dyspepsia using a random starting day trial--is gastro-oesophageal reflux important?

BACKGROUND

Single subject trials offer an alternative approach to identify and characterize responders to a specific treatment.

AIM

To test a new single subject trials design, called random starting day trial, to identify acid-related symptoms in dyspepsia.

METHODS

A total of 119 patients with functional dyspepsia entered a 12-day, double-blind random starting day trial. All patients started on placebo and switched to omeprazole 80 mg/day at a randomized and blinded day between day 5 and day 9, with active treatment continuing for the rest of the trial. Based on changes of a daily symptom score, response was defined as a sustained > or =50% reduction of symptoms within 3 days of active treatment.

RESULTS

Thirteen of 119 patients (11%) were classified as spontaneous responders because of complete symptom relief before switching to omeprazole. Of the remaining 106 patients, 15 (15.6%) were classified as responders. Five of six (83%) responders compared with 28 of 53 (53%) non-responders had pathological reflux. Multivariate testing identified symptoms suggestive of gastro-oesophageal reflux predictive of response.

CONCLUSIONS

The random starting day trial design could identify a subset of dyspeptic patients with a uniform symptomatic response to acid-suppressive therapy. Response seems to be associated with gastro-oesophageal reflux. The random starting day trial needs to be further validated to be considered as a reliable instrument in clinical research.

Treatment of functional dyspepsia with a herbal preparation. A double-blind, randomized, placebo-controlled, multicenter trial

BACKGROUND

We aimed to assess the efficacy and safety of a herbal preparation STW 5-II containing extracts from bitter candy tuft, matricaria flower, peppermint leaves, caraway, licorice root and lemon balm for the treatment of patients with functional dyspepsia.

METHODS

120 patients with functional dyspepsia were randomly assigned to 1 of 4 treatment groups. Each patient received the treatment for three consecutive 4-week treatment blocks. The first two treatment blocks were fixed. For the third treatment period, medication was based upon the investigator's judgement of symptom improvement during the preceding treatment period. In patients without adequate control of symptoms, the treatment was switched, or if symptoms were controlled, the treatment was continued. The primary outcome measure was the improvement of a standardized gastrointestinal symptom score (GIS).

FINDINGS

During the first 4 weeks, the GIS significantly decreased in subjects on active treatment compared to the placebo (p < 0.001). During the second 4-week period, symptoms further improved in subjects who continued on active treatment or who switched to the active treatment (p < 0.001), while symptoms deteriorated in subjects who switched to placebo. After 8 weeks 43.3% on active treatment and 3.3% on placebo reported complete relief of symptoms. (p < 0.001 vs. placebo).

CONCLUSION

In patients with functional dyspepsia, the herbal preparation tested improved dyspeptic symptoms significantly better than placebo.

Lansoprazole in the treatment of functional dyspepsia: two double-blind, randomized, placebo-controlled trials

PURPOSE

The efficacy of proton pump inhibitor therapy for symptom resolution in patients with functional dyspepsia remains controversial. This study was designed to compare the efficacy of lansoprazole with placebo in relieving upper abdominal discomfort in patients with functional dyspepsia.

METHODS

We enrolled 921 patients with functional dyspepsia (defined as persistent or recurrent upper abdominal discomfort during the prior 3 months) and moderate upper abdominal discomfort on at least 30% of screening days; none of the patients had predominant symptoms suggestive of gastroesophageal reflux or endoscopic evidence of erosive or ulcerative esophagitis, or gastric or duodenal ulcer or erosion. Patients were assigned randomly to receive lansoprazole 15 mg (n = 305), lansoprazole 30 mg (n = 308), or placebo (n = 308) daily for 8 weeks. Patients recorded the frequency and severity of symptoms in daily diaries.

RESULTS

At week 8, significantly (P <0.001) greater mean reductions in the percentage of days with upper abdominal discomfort were reported in patients treated with lansoprazole 15 mg (35%) or 30 mg (34%) compared with those treated with placebo (19%). Similarly, more patients treated with lansoprazole 15 mg (44%) or 30 mg (44%) reported complete symptom resolution (defined as no episodes of upper abdominal discomfort in the 3 days before the study visit) at 8 weeks than did placebo-treated patients (29%, P <0.001). Improvement of upper abdominal discomfort, however, was seen only in patients who had at least some symptoms of heartburn at enrollment.

CONCLUSION

Lansoprazole, at a daily dose of 15 mg or 30 mg, is significantly better than placebo in reducing symptoms of persistent or recurrent upper abdominal discomfort accompanied by at least some symptoms of heartburn.

Functional dyspepsia: motor abnormalities, sensory dysfunction, and therapeutic options

Functional dyspepsia is a common condition, but as yet, the underlying etiology is unclear. In this article, upper gastrointestinal motor and sensory physiology are reviewed and the current evidence for motor and/or sensory functional abnormalities causing dyspeptic symptoms is presented. The complex interrelationship between abnormal motor activity and sensation is explored, as well as the potential roles for autonomic dysfunction and psychological state in modulating gastrointestinal sensation and motor function. Finally, based on clinical trial evidence, a treatment pathway for functional dyspepsia is suggested.

Levosulpiride and cisapride in the treatment of dysmotility-like functional dyspepsia: a randomized, double-masked trial

BACKGROUND & AIMS

Levosulpiride is a benzamide derivate D(2) dopamine antagonist with prokinetic activity that can accelerate gastric emptying and reduce discomfort in response to gastric distention. The aim of the study is to compare the clinical efficacy of levosulpiride and cisapride in patients with dysmotility-like functional dyspepsia.

METHODS

In a exploratory pilot study performed as a multicenter, randomized, double-masked trial, the effects of 8 weeks of treatment with either levosulpiride, 25 mg, 3 times daily (n = 69) or cisapride, 10 mg, 3 times daily (n = 71) were compared. Individual symptoms (pain/discomfort, fullness, bloating, early satiety, and nausea/vomiting), global symptom score, effect on health-related quality of life (HRQoL), and anxiety-state and anxiety-trait were evaluated. Adverse events also were recorded.

RESULTS

Both levosulpiride and cisapride improved dyspeptic symptoms and decreased total symptom score (79.9% and 71.3%, respectively); no significant statistical difference between treatments was found (P = 0.07 for total symptom score). HRQoL improved similarly after both treatments, whereas no change was observed in anxiety. Medication-related adverse effects were present in 13 of 69 patients (18.8%) in the levosulpiride group and 8 of 71 patients (11.3%) in the cisapride group. Significantly more (P = 0.03) patients treated with cisapride had to abandon the trial because of side effects.

CONCLUSIONS

Levosulpiride is at least as effective as cisapride in the treatment of dysmotility-like functional dyspepsia.

Systematic review: the methodological quality of trials affects estimates of treatment efficacy in functional (non-ulcer) dyspepsia

AIM

To evaluate treatment efficacy using objective quality criteria.

METHODS

A systematic review was performed of randomized controlled trials of endoscopically investigated dyspepsia (1979-2003) using the Jadad score and Rome II guidelines. The Jadad score differentiated studies as 'high quality' (score 4-5/5) vs. 'poor quality' (score 1-3/5). Three key Rome II guidelines on study design (cut-off of 0/3 or > 0/3) were also compared with the Jadad score.

RESULTS

Poor quality trials suggested a benefit of prokinetic therapy [relative risk (RR) of remaining dyspeptic, 0.47; 95% confidence interval (CI), 0.39-0.56), which was not confirmed in high quality trials (RR, 1.0; 95% CI, 0.84-1.19). There was a marked benefit of H2-receptor antagonist therapy in poor quality trials (RR, 0.68; 95% CI, 0.61-0.76), but a marginal benefit in good quality trials (RR, 0.87; 95% CI, 0.79-0.97). Trial quality did not affect the small statistically significant benefit seen with Helicobacter pylori eradication. Two high quality trials suggested a limited benefit with the use of proton pump inhibitors, with no poor quality trials to provide a comparison. Separation of the studies by the Rome II criteria had a similar impact on the calculated treatment estimates.

CONCLUSIONS

The magnitude of benefit of prokinetic and H2-receptor antagonist therapies reported in previous meta-analyses has been over-estimated. The quality of trials has an impact on the efficacy estimates of treatment. The Rome II criteria for study methodology may be appropriate for judging study quality.

Dyspeptic symptoms associated with Helicobacter pylori infection are influenced by strain and host specific factors

BACKGROUND

Dyspepsia can be associated with H. pylori infection.

AIM

To assess dyspeptic symptoms and potentially influencing factors before and up to 6 months following successful H. pylori eradication therapy.

METHODS

Prospective cohort study involving H. pylori positive subjects from ambulatory or hospitalized care. Main outcome measures were symptoms during baseline and follow-up, the proportion of symptom-free patients, and symptom scores.

RESULTS

After successful eradication, the summary score of all dyspeptic symptoms decreased and during follow-up, the proportion of symptom-free patients was higher in the group with peptic ulcers (69.4% vs. 40.9%, P < 0.0001) than with functional dyspepsia (FD). Regardless of diagnosis, virulent strains of H. pylori were associated with a higher prevalence of epigastric pain before treatment: absolute risk-difference (ARD) with Oip-A: 18.2%, Odds Ratio (OR) 2.35 [1.3-4.2, 95%-CI], P = 0.01; with Cag-A: 24.6%, OR 2.81 [1.6-5], P = 0.01. Low-dose aspirin in part was a major risk factor in FD for previous weight loss bdfore study entry. Post-treatment, non-ulcer patients were more likely to suffer from distention/bloating. Likewise, alcohol induced persistence of nausea and vomiting in this population.

CONCLUSIONS

Dyspeptic symptoms in H. pylori infected patients are more common with virulent strains. Symptoms are more likely to persist despite successful eradication if patients initially harboured virulent strains or concomitant aspirin or alcohol intake are present. In one-third of peptic ulcer patients, symptoms will not be cured 3 months after therapy.

Efficacy of artichoke leaf extract in the treatment of patients with functional dyspepsia: a six-week placebo-controlled, double-blind, multicentre trial

BACKGROUND

This study aimed to assess the efficacy of artichoke leaf extract (ALE) in the treatment of patients with functional dyspepsia (FD).

METHODS

In a double-blind, randomized controlled trial (RCT), 247 patients with functional dyspepsia were recruited and treated with either a commercial ALE preparation (2 x 320 mg plant extract t.d.s.) or a placebo. The primary efficacy variable was the sum score of the patient's weekly rating of the overall change in dyspeptic symptoms (four-point scale). Secondary variables were the scores of each dyspeptic symptom and the quality of life (QOL) as assessed by the Nepean Dyspepsia Index (NDI).

RESULTS

Two hundred and forty-seven patients were enrolled, and data from 244 patients (129 active treatment, 115 placebo) were suitable for inclusion in the statistical analysis (intention-to-treat). The overall symptom improvement over the 6 weeks of treatment was significantly greater with ALE than with the placebo (8.3 +/- 4.6, vs. 6.7 +/- 4.8, P < 0.01). Similarly, patients treated with ALE showed significantly greater improvement in the global quality-of-life scores (NDI) compared with the placebo-treated patients (- 41.1 +/- 47.6 vs. - 24.8 +/- 35.6, P < 0.01).

CONCLUSION

The ALE preparation tested was significantly better than the placebo in alleviating symptoms and improving the disease-specific quality of life in patients with functional dyspepsia.

Gastric mucosal fibrosis: a novel explanation for dyspepsia

The etiology of functional dyspepsia has not been discerned yet which has led to inadequate treatment of this disease. It remains a common disorder with expensive and yet often ineffective therapy. We propose that the pathogenesis of this disease lies in the histological and ultrastructural changes inflicted on the gastric mucosa in chronic gastritis and fibrosis. This hypothesis, if substantiated will provide for therapy which will be based on the pathogenesis of the disease and which will be cheaper and easily available to most. It will also add impetus to the early eradication of Helicobacter pylori, which would prevent chronic gastritis and hence gastric fibrosis.

Helicobacter pylori eradication is beneficial in the treatment of functional dyspepsia

AIM

To assess whether the eradication of Helicobacter pylori leads to long-term relief of symptoms in functional dyspepsia.

METHODS

Eight hundred patients with functional dyspepsia were randomized to receive double-blind treatment with twice-daily 30 mg lansoprazole, 1000 mg amoxicillin and 500 mg clarithromycin for 7 days (L30AC), twice-daily 15 mg lansoprazole, 1000 mg amoxicillin and 500 mg clarithromycin for 7 days (L15AC), or once-daily 15 mg lansoprazole for 14 days (LP). Dyspepsia and reflux symptoms were monitored for 12 months.

RESULTS

In intention-to-treat analysis, the non-ulcer dyspepsia sum score showed a statistically significant benefit in terms of symptom relief in the L30AC group (P = 0.0068) compared with the LP group, but there was no significant difference between the L15AC and LP groups (P = 0.2). When all patients in the two eradication therapy arms were considered together, successful eradication had a significant benefit with regard to the complete absence of symptoms (P < 0.04). H. pylori eradication did not lead to an increase in reflux symptoms.

CONCLUSION

This study suggests that H. pylori infection causes dyspeptic symptoms in a subset of patients with functional dyspepsia, and that these patients may obtain long-term symptomatic benefit following H. pylori eradication.

Treatment of Functional Dyspepsia

Because there is currently no universally effective treatment for functional dyspepsia, a stepwise approach is useful. The initial steps should include 1) making a firm clinical diagnosis and providing the patient with appropriate information and reassurance; 2) ascertaining the reason for referral/consultation, as this determines what the patient will regard as a satisfactory outcome; 3) informing the patient that there is no universally effective drug treatment; and 4) giving dietary and general lifestyle advice, such as ingestion of smaller, more frequent meals, a low-fat diet, avoidance of certain foods that may exacerbate symptoms, limiting coffee and alcohol intake, smoking cessation, and stress management techniques. If the initial approach does not provide a satisfactory outcome, the following approaches may be helpful. Psychologic treatment approaches, such as hypnotherapy and/or antidepressants, have shown very encouraging results in recent studies and deserve active consideration. In patients with uninvestigated dyspepsia, the "test and treat" strategy for Helicobacter pylori is a cost-effective approach. Prokinetics are of possible benefit in subjects with delayed gastric emptying; however, the relationship between improvement of gastric emptying and symptom alleviation is weak. Furthermore, it needs to be recognized that treatments directed at acid suppression are generally of little sustained benefit, and that there is ongoing controversy as to whether H. pylori eradication is of direct benefit.

Nonulcer dyspepsia

Nonulcer dyspepsia is a common condition in clinical practice. It is a heterogeneous disorder, and no single therapeutic agent is effective in all patients. The treatment of nonulcer dyspepsia is still dissatisfactory. Eradication of Helicobacter pylori organisms has a limited role and little effect. Antisecretory therapy has a modest effect in alleviating symptoms. Prokinetic agents may be effective, but selection bias in the trials performed to date may exaggerate their benefit. Partial 5-HT(4) agonists stimulate gastric emptying and may also affect gastric accommodation. They are promising but need further study. Data are limited on 5-HT(3) antagonists and hypnotherapy. New treatment approaches are necessary for this common and often chronic condition.

A rational approach to uninvestigated dyspepsia in primary care: review of the literature

In this paper the rationale and limitations of the four most important approach strategies to dyspepsia in primary care (empiric treatment, prompt endoscopy, "test-and-scope", and "test-and-treat") are analysed. It is concluded that in the absence of alarm symptoms, a "test-and-treat" approach is currently the most rational approach provided that three conditions are met: (1) a highly accurate test should be used, (2) the prevalence of Helicobacter pylori in the population should not be too low, and (3) an effective anti-H pylori regimen should be prescribed taking sufficient time to instruct and motivate the patient.

A randomized placebo-controlled trial of simethicone and cisapride for the treatment of patients with functional dyspepsia

AIM

To compare the efficacy of simethicone with placebo and the prokinetic cisapride in patients with functional dyspepsia.

METHODS

One hundred and eighty-five patients with functional dyspepsia were randomized and treated in a double-dummy technique with simethicone (105 mg t.d.s.), cisapride (10 mg t.d.s.) or placebo (t.d.s.). The primary outcome measure was the O'Brien global measure of the patients' rating of 10 upper gastrointestinal symptoms (graded as absent = 0, moderate = 1, severe = 2 or very severe = 3). Outcome measures were assessed at baseline and after 2, 4 and 8 weeks of treatment (intention-to-treat).

RESULTS

At 2, 4 and 8 weeks, treatment with simethicone and cisapride yielded significantly (all P values < 0.0001) better improvement of symptoms compared to placebo. Simethicone was significantly better than cisapride after 2 weeks (P = 0.0007), but the differences were not statistically significant after 4 and 8 weeks. Patients treated with simethicone judged the efficacy of their treatment as very good in 46% of cases, compared to 15% and 16% receiving cisapride and placebo, respectively.

CONCLUSIONS

Simethicone and cisapride were significantly better than placebo for symptom control in patients with functional dyspepsia after 2, 4 and 8 weeks of treatment. Simethicone was also superior to the prokinetic cisapride in the first 2 weeks of treatment.

Serotonergic modulating drugs for functional gastrointestinal diseases

After many years of basic research we have now begun to learn how to manipulate the serotonergic mechanisms within the gut. This has lead to a number of significant advances including 5HT3 antagonists for the treatment of functional diarrhoea, 5HT4 agonists for the treatment of constipation and 5HT1 agonists for the treatment of impaired fundal relaxation. Initial enthusiasm has been somewhat dented by the withdrawal of alosetron because of ischaemic colitis, but it remains to be seen whether this adverse event will be seen with other 5HT3 antagonists. Finally it should be recognized that, in a substantial proportion of patients attending clinics complaining of functional symptoms, anxiety is a major component. The drugs so far described are by and large devoid of CNS effects. It remains possible therefore that a drug which combines both peripheral and central effects would likely to be beneficial.

Dose finding study of mosapride in functional dyspepsia: a placebo-controlled, randomized study

BACKGROUND

Prokinetic agents have shown variable efficacy in the treatment of functional dyspepsia. Mosapride is a new prokinetic 5-hydroxytryptamine-4 agonistic agent.

AIM

To evaluate the efficacy of three dosage regimens of mosapride compared with placebo in the treatment of functional dyspepsia.

METHODS

Patients were randomly allocated to treatment with placebo or mosapride (5 mg b.d., 10 mg b.d. or 7.5 mg t.d.s.) in a double-blind, prospective, multicentre, multinational study. The change in symptom severity score from an untreated baseline week to the sixth week of treatment was used to compare treatment efficacy.

RESULTS

There were 141, 140, 143 and 142 patients valid for evaluation in the intention-to-treat population in the placebo, mosapride 5 mg b.d., mosapride 10 mg b.d. and mosapride 7.5 mg t.d.s. groups, respectively. The mean changes in the overall dyspeptic symptom score were - 0.90, - 0.94, - 0.88 and - 0.89, respectively, and the proportions of patients feeling better at the end of the treatment period were 60%, 59%, 59% and 61%, respectively. No statistically significant difference was seen.

CONCLUSIONS

Treatment of functional dyspepsia with mosapride was not superior to placebo. The result raises the question of whether treatment with prokinetic agents is appropriate for functional dyspepsia.

Functional (Nonulcer) Dyspepsia

Functional (nonulcer) dyspepsia refers to upper abdominal pain or discomfort with or without symptoms of early satiety, nausea, or vomiting with no definable organic cause. The current Rome II criteria help to diagnose functional dyspepsia and avoid misdiagnosis of gastroesophageal reflux disease and irritable bowel syndrome as functional dyspepsia. Assessment of gastric emptying with scintigraphy or breath testing may be useful in identifying delayed gastric emptying in patients with dyspeptic symptoms and may be helpful in patient management. Electrogastrography is a noninvasive test that evaluates for gastric dysrhythmias. Satiety testing is being evaluated as an indirect test for impaired fundic relaxation and visceral hypersensitivity. The symptom response to Helicobacter pylori therapy in patients with functional dyspepsia and a negative endoscopy examination but a positive H. pylori test is marginal. Lifestyle modifications often are suggested for initial treatment of functional dyspepsia. Dietary changes such as frequent small meals, low-fat diet, and avoidance of certain aggravating foods may improve symptoms. Additional measures include cessation of smoking, avoiding excess alcohol intake, and minimizing coffee intake. Antacids and over-the-counter histamine type 2 receptor antagonists may be helpful as an "on-demand" therapy for intermittent symptoms. They are safe and relatively inexpensive. Different subgroups of functional dyspepsia are based on the predominant symptom and may help in choosing an appropriate drug to initiate therapy. If the predominant symptom is epigastric pain (ulcer-like functional dyspepsia), histamine-2 receptor antagonists or proton pump inhibitors are the initial treatment of choice. If fullness, bloating, early satiety or nausea is the predominant complaint (dysmotility-like functional dyspepsia), a prokinetic agent may help. Metoclopramide is the only available effective prokinetic agent at present. If metoclopramide is used, short-term treatment and discussion of possible side effects with the patient are advised. If there is no response to these initial treatments, switching therapy from proton pump inhibitor to prokinetic or vice versa can be tried. If these treatment options fail, patient re-evaluation for other disorders (including other functional bowel disorders) is advised. A low-dose tricyclic antidepressant at bedtime may be helpful for treatment of visceral hypersensitivity.

Treatment options for functional dyspepsia

Non-ulcer dyspepsia is a common condition in primary care. The treatment of this condition is still controversial and no single therapy is uniformly effective. In this article we review currently available treatment trials for non-ulcer dyspepsia.

H2-receptor antagonists in the treatment of functional (nonulcer) dyspepsia: a meta-analysis of randomized controlled clinical trials

AIM

To perform a meta-analysis evaluating the efficacy of H2-receptor antagonists in functional (nonulcer) dyspepsia.

SELECTION OF STUDIES

A Medline search was used to identify placebo controlled randomized clinical trials, using the subject headings dyspepsia and H2-receptor antagonist.

OUTCOME MEASURES

Global assessment by the patient of dyspepsia symptoms, improvement of epigastric pain and complete relief of epigastric pain.

RESULTS

Twenty-two studies met the inclusion criteria, 15 of which reported the active drug to be superior to placebo. Many studies suffered from suboptimal study design. The odds ratio in favour of active drug was 1.48 (95% confidence interval: 0.9-2.3) for global assessment of dyspepsia symptoms, 2.3 (95% CI: 1.6-3.3) for improvement of epigastric pain, and 1.8 (95% CI: 1.2-2.8) for complete relief of epigastric pain.

CONCLUSION

There is some evidence that H2-receptor antagonists are superior to placebo in functional dyspepsia, but larger studies evaluating higher doses of H2-receptor antagonists and of longer duration are necessary to determine the exact effect size.

There are some benefits for eradicating Helicobacter pylori in patients with non-ulcer dyspepsia

BACKGROUND

The relationship between Helicobacter pylori infection and non-ulcer dyspepsia is not established.

AIM

To determine whether eradication of H. pylori might be of benefit in non-ulcer dyspepsia patients.

METHODS

We randomly assigned 129 H. pylori infected patients with severe epigastric pain, without gastro-oesophageal reflux symptoms, to receive twice daily treatment with 300 mg of ranitidine, 1000 mg of amoxicillin, and 500 mg of clarithromycin for 7 days and 124 such patients to receive identical-appearing placebos.

RESULTS

Treatment was successful (decrease of symptoms at 12 months) in 62% of patients in the active-treatment group and in 60% of the placebo group (N.S.). At 12 months, the rate of eradication of H. pylori was 69% in the active-treatment group and 18% in the placebo group (P < 0.001). Complete relief of symptoms occurred significantly more frequently in patients on the active treatment (43%) than in placebo-treated patients (31%, P=0.048). Within the active-treatment group, therapeutic success was significantly more frequent in the non-infected patients (84% vs. 64%, P=0.04).

CONCLUSIONS

Although eradicating H. pylori is not likely to relieve symptoms in the majority of patients with non-ulcer dyspepsia, a small proportion of H. pylori-infected patients may benefit from eradication treatment.

Augmented Visceral Perception

Disorders of augmented visceral perception include functional (or nonulcer) dyspepsia and irritable bowel syndrome (IBS). Enhancement of luminal perception can result from alterations in normal elastic gut wall properties or exaggerated responsiveness of visceral sensory nerve pathways. Standard therapies for functional dyspepsia are effective in subsets of patients and may act in part by compensating for gastric hypersensitivity (as with acid-suppressing drugs) or by enhancing gastric compliance (as with some motor-stimulating agents). Likewise, conventional treatments of patients with IBS reduce visceral perception via effects on sensory nerve function (fiber supplements) or luminal wall properties (antispasmodic drugs). Antidepressants are increasingly used in patients with functional dyspepsia or IBS. These drugs have several purported mechanisms, including 1) luminal relaxation, 2) blunting of visceral hypersensitivity, and 3) modulation of central nervous system pain processing pathways. The efficacy of available and investigational agents that act as visceral analgesics or luminal relaxants is an area of intense pharmaceutical research.

Nonulcer Dyspepsia

There is currently no effective treatment for patients with nonulcer dyspepsia. Helicobacter pylori eradication has no beneficial effect on dyspeptic symptoms. Proton pump inhibitors are superior to placebo in the subset of patients with epigastric pain as the predominant symptom. H(2 )Receptor antagonists have no effect. Patients with dysmotility-like dyspepsia should be treated first with prokinetics. Unfortunately, cisapride no longer can be used to treat patients with functional dyspepsia because of reports of serious cardiovascular side effects and subsequent withdraw from the US market. Therefore, metoclopramide (or domperidone, if available) should be given. Treatment with motilides has no use in the relief of symptoms, even in patients with delayed gastric emptying. If the initial therapy has no effect after 4 weeks, switch treatment (eg, from proton pump inhibitor to metoclopramide or vice versa). If both of these pharmacologic therapies fail, consider treatment with an antidepressant (or with buspirone, an anxiolytic agent) or psychotherapy.