NICE guidance - management of dyspepsia in adults in primary care (summary section)

Last edited 03/2019 and last reviewed 06/2021

Referral for endoscopy

• review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal antiinflammatory drugs [NSAIDs]). In patients requiring referral, suspend NSAID use

• NICE cancer referral guidance states (2):

  • Suspected Oesophageal cancer

    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer n people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia

    Suspected Stomach cancer

    • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer
    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for stomach cancer in people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia

    Non Urgent Referral guidance:

    Suspected stomach cancer/oesophageal cancer:

    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people with haematemesis
      
      
    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people aged 55 or over with:
      • treatment-resistant dyspepsia or
        
        
      • upper abdominal pain with low haemoglobin levels or
        
        
      • raised platelet count with any of the following:
        • nausea
        • vomiting
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain, or
          
          
      • nausea or vomiting with any of the following:
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain

Interventions for uninvestigated dyspepsia

• initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori
• there is currently insufficient evidence to guide which should be offered first
• a 2- week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test

Interventions for gastro-oesophageal reflux disease (GORD)

• offer people a full-dose PPI (see table 1 in notes) for 8 weeks to heal severe oesophagitis, taking into account the person's preference and clinical circumstances (for example, underlying health conditions and possible interactions with other drugs).
• offer a full-dose PPI (see notes) long-term as maintenance treatment for people with severe oesophagitis, taking into account the person's preference and clinical circumstances (for example, tolerability of the PPI, underlying health conditions and possible interactions with other drugs), and the acquisition cost of the PPI
• do not routinely offer endoscopy to diagnose Barrett's oesophagus, but consider it if the person has GORD. Discuss the person's preferences and their individual risk factors (for example, long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender).

Interventions for peptic ulcer disease

• offer H pylori eradication therapy to people who have tested positive for H pylori and who have peptic ulcer disease
• for people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI (see table 2) or H2RA therapy for 8 weeks and, if H pylori is present, subsequently offer eradication therapy
• offer people with peptic ulcer (gastric or duodenal) and H pylori retesting for H pylori 6 to 8 weeks after beginning treatment, depending on the size of the lesion

Interventions for functional dyspepsia

• management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring
• re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients

Referral to a specialist service

• consider referral to a specialist service for people:
  • of any age with gastro-oesophageal symptoms that are non-responsive to treatment or unexplained
  • with suspected GORD who are thinking about surgery
  • with H pylori that has not responded to second-line eradication therapy

Reviewing patient care

• offer patients requiring long-term management of symptoms for dyspepsia an annual review of their condition, encouraging them to try stepping down or stopping treatment
• a return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as required) may be appropriate

H. pylori testing and eradication

• H. pylori can be initially detected using either a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance
• for patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with additional medication as described in linked item

For full details then refer to the full guideline (1).

Notes:

• Table 1: PPI doses for severe oesophagitis

  PPI	Full/Standard dose	Low dose (on demand dose)	Double dose
  Esomeprazole	40 mg once a day	20mg once a day	40 mg twice a day
  Lansoprazole	30mg once a day	15mg per day	30 mg twice a day
  Omeprazole	40 mg once a day	20mg per day	40 mg twice a day
  Pantoprazole	40 mg once a day	20mg per day	40mg twice a day
  Rabeprazole	20mg once a day	10mg per day	20mg twice a day

  
  
• Table 2: PPI doses for peptic ulcer disease

  PPI	Full/Standard dose	Low dose (on demand dose)	Double dose
  Esomeprazole	20 mg* once a day	Not available	40 mg*** once a day
  Lansoprazole	30mg once a day	15mg per day	30 mg** twice a day
  Omeprazole	20 mg once a day	10mg* per day	40 mg once a day
  Pantoprazole	40 mg once a day	20mg per day	40mg twice a day
  Rabeprazole	20mg once a day	10mg per day	20mg twice a day

• * lower than the licensed starting dose for esomeprazole in GORD, which is 40 mg, but considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of doserelated effects, NICE classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg
• **Off-label dose for GORD

• ***40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to omeprazole 20 mg.

Reference:

• (1) NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both
• (2) NICE (June 2015). Referral Guidelines for Suspected Cancer.
• (3) NPC. Dyspepsia. MeReC Briefing (March 2006); 32:1-8.