Discussions of treatment options (including lifestyle modifications and surgery) for specific conditions (i.e. gallstones, GERD, gastroparesis/ dysmotility, Helicobacter pylori infection, etc.) can be found in the pages that address particular disorders. The following is a description of different medical treatments available for the symptoms of dyspepsia. Many of these treatments may also be used for GERD and other conditions which cause symptoms of dyspepsia. These treatments fall into several groups.

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Antacids

These medications contain one or more compounds based on calcium, magnesium, aluminium or sodium bicarbonate. They work by neutralising gastric acid in the stomach or, in patients with reflux disease, in the esophagus. Some antacids are also combined with another compound, such as an alginate, which is intended to coat and protect the lining of the esophagus and stomach.

Antacids can be bought 'over-the-counter' (OTC), without a doctor's prescription. If used in accordance with the instructions, they are safe although some may cause diarrhea, some may cause constipation and some should be used with caution by people with kidney problems.

Antacids often provide rapid relief, particularly for milder symptoms, but they have not been shown to be effective in the long run for dyspepsia, reflux disease or peptic ulcer disease. In addition, they must be taken frequently, up to 4 to 7 times per day, for more severe symptoms.

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Acid secretion blockers

There are two types of medication which reduce acid secretion: H2-blockers (histamine H2-receptor antagonists) and PPIs (proton pump inhibitors).

H2-blockers
These medications work by blocking the effect of histamine (a chemical secreted in the stomach) which would normally stimulate the parietal cells in the stomach to produce gastric acid. The first H2-blocker, cimetidine (Tagemet®) become available 25 years ago and it was followed by ranitidine (Zantac®), famotidine (Pepcid®) and nizatidine (Axid®). H2-blockers are all available as prescription medications and some are available in lower dose, 'over-the-counter' (OTC), without a doctor's prescription.

H2-blockers are generally very safe and they are effective for mild to moderate reflux disease (GERD) and, possibly, for dyspepsia but they are less effective than proton pump inhibitors. They are usually taken twice daily although, in some cases, as single night-time dose may be effective.

Proton Pump Inhibitors
These medications work by blocking the enzyme (H+-K+ ATPase) in the parietal cells which secrete acid into the stomach. They are much more effective at reducing acid secretion than H2-blockers and they have been shown to be effective than H2-blockers for the treatment of gastroesophageal reflux disease (GERD), peptic ulcer and non-ulcer dyspepsia. The first PPI, omeprazole (Losec®, Prilosec®, Antra®) was introduced 10-15 years ago and has been followed by lansoprazole (Prevacid®), pantoprazole (Pantoloc®, Protonix®), rabeprazole (AcipHex®, Pariet®) and esomeprazole (Nexium®). PPIs are available only as prescription medications. PPIs are generally very safe and they are effective for gastroesophageal reflux disease (GERD), peptic ulcer disease and dyspepsia; in combination with antibiotics, they are also very effective for curing Helicobacter pylori infection in patients with peptic ulcer disease and dyspepsia.

PPIs are usually taken once daily (in the morning, about 30 minutes before breakfast) although, in some cases, as second dose (before the evening meal) may be necessary.

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Motility agents

A high proportion of people with dyspepsia have symptoms which suggest an abnormality of motility (contractions) in the stomach or small intestine. Some of these patients will improve with medications which can regulate gastrointestinal motility - these are often known as 'prokinetic' or promotility' agents.

Metoclopramide (Maxeran®, Maxolon®, Reglan®)
This medication can help relieve nausea and improve gastric emptying. It is useful in a small proportion of patients but it can also have side effects in some. It is not used widely for dyspepsia. It is usually taken 3 to 4 times daily, before meals.

Domperidone (Motilium®)
This medication can help relieve dyspeptic symptoms and improve gastric emptying. It is useful in a proportion of patients but it is generally safe although it can cause a (benign) discharge from the breasts: the discharge stops when the medication is stopped. It is usually taken 3 to 4 times daily, before meals.

Cisapride (Prepulsid®, Propulsid®)
This medication can relieve dyspeptic symptoms and improve gastric emptying. It is the best documented and most effective of the motility agents but it has been withdrawn from general use in most countries because of rare heart rhythm irregularites. It is usually taken 3 to 4 times daily, before meals.

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Protective agents

Sucralfate (Sulcrate®)
This medication is a complex of sucrose and aluminium. It has been used to treat peptic ulcer and, occasionally, esophagitis. The precise mechanism of action is not known and it is not widely used. It is usually taken 4 times daily.

Misoprostol (Cytotec®)
This medication belongs to a class of medications known as prostaglandin analogues. It reduces gastric acid secretion but is less effective than H2-blockers or PPIs; it also provides some protection against damage caused by other agents such as arthritis medications (NSAIDs - non-steroidal anti-inflammatory drugs; ASA - acetylsalicylic acid). Most commonly, it is used to reduce the development of ulcers in patients who need to continue taking NSAIDs. It is generally used for normal peptic ulcer disease or reflux disease. It can cause abdominal cramps and diarrhoea and it should not be taken during pregnancy as it can cause abortion. It is usually taken 2 to 4 times daily.

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Helicobacter pylori eradication therapy

Cure of H. pylori cures peptic ulcer disease in most patients and prevents recurrent complications such as bleeding or perforation. It has also been shown to produce symptom relief in a proportion of patients with non-ulcer dyspepsia or 'uninvestigated dyspepsia'. In the latter case, patients with uninvestigated dyspepsia are those who have a positive urea breath test but have not had an endoscopy to confirm peptic ulcer disease.

PPI-Triple Therapy
This is the most widely-used treatment combination: a PPI with two antibiotics, taken twice daily. This treatment is generally taken for one week although in some countries, a two-week course is recommended. The PPI can be omeprazole, lansoprazole, pantoprazole, rabeprazole or esomeprazole; the antibiotics are usually a combination of clarithromycin (Biaxin®) + metronidazole (Flagyl®), amoxicillin (Amoxil®) or metronidazole (Flagyl®) + amoxicillin (Amoxil®). Other antibiotics, such as rifabutin, furazolidone or tetracycline are used occasionally if PPI-triple therapy has not worked.

The cure rates with these combinations range from 80% to 90+%; side effects include nausea, vomiting, a metallic taste in the mouth and diarrhoea.

Bismuth-Triple Therapy
This was the one of the first combinations studied: it consists of a one- to two-week course of bismuth (Pepto-Bismol®), metronidazole (Flagyl®) and tetracycline, all taken four times daily. The cure rates with this combination range from 80% to 90%; side effects include nausea, vomiting, a metallic taste in the mouth, diarrhoea and black stools (which are not due to bleeding). This combination requires the patients to take more tablets (up to 16/day) than PPI-triple therapy and it is generally less well-tolerated.

PPI-Bismuth Quadruple Therapy
This combination is the same as Bismuth-triple therapy with the addition of a PPI, taken twice daily. It is generally reserved for patients whose infection has not been cured by one or two courses of a PPI-tripe regimen. The cure rates with this combination range from 80% to 95%; side effects include nausea, vomiting, a metallic taste in the mouth, diarrhoea and black stools (which are not due to bleeding).

Ranitidine bismuth citrate
Ranitidine bismuth citrate (Pylorid®) has been used in combination with clarithromycin (Biaxin®) for two weeks and in combination with clarithromycin (Biaxin®) + amoxicillin (Amoxil®) or metronidazole (Flagyl®) for one week. The cure rates are comparable to those for other combinations but it is not widely available.

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Other therapy

If dyspeptic symptoms have been shown not to be due to an underlying condition such as reflux disease, ulcer disease, etc and, if first-line treatments, listed above, are ineffective or inappropriate, treatment directed at reducing stress, anxiety and depression may be helpful. Although there are very few studies, antidepressants, such as amitriptylline or imipramine and psychological intervention, such as cognitive behavioural therapy may help.