First-line treatment of FD
We recommend that all patients with FD are advised to take regular aerobic exercise (recommendation: strong, quality of evidence: very low).

There is insufficient evidence to recommend dietary therapies, including a diet low in fermentable oligosaccharides, disaccharides and monosaccharides, and polyols in FD (recommendation: weak; quality of evidence: very low).

Eradication therapy is an efficacious treatment for H. pylori-positive patients with FD. Adverse events are more common than with a control therapy (recommendation: strong; quality of evidence: high).

Histamine-2-receptor antagonists may be an efficacious treatment for FD. These drugs are well tolerated (recommendation: weak, quality of evidence: low).

Proton pump inhibitors (PPIs) are an efficacious treatment for FD. There does not appear to be a dose response, so the lowest dose that controls symptoms should be used. These drugs are well tolerated (recommendation: strong, quality of evidence: high).

Some prokinetics may be an efficacious treatment for FD. However, efficacy varies according to drug class, and many of these drugs are unavailable outside of Asia and the USA. Most of these drugs are well tolerated (recommendation: weak, quality of evidence: low for acotiamide, itopride, and mosapride, recommendation: strong, quality of evidence: moderate for tegaserod).

Second-line treatment of FD
Tricyclic antidepressants (TCAs) used as gut–brain neuromodulators are an efficacious second-line treatment for FD. They can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side effect profile. They should be commenced at a low dose (eg, 10 mg amitriptyline once daily) and titrated slowly to a maximum of 30–50 mg once daily (recommendation: strong, quality of evidence: moderate).

Antipsychotics, such as sulpiride 100 mg four times a day or levosulpiride 25 mg three times a day, may be efficacious as a second-line treatment for FD. There should be careful explanation as to the rationale for their use and patients should be counselled on their side effect profile (recommendation: weak, quality of evidence: low).

There is no evidence that selective serotonin reuptake inhibitors (SSRIs) used as gut–brain neuromodulators are an efficacious second-line drug for global symptoms in FD (recommendation: weak, quality of evidence: moderate).

There is no evidence that serotonin norepinephrine reuptake inhibitors (SNRIs) used as gut–brain neuromodulators are an efficacious second-line drug for global symptoms in FD. However, as they are efficacious in other chronic painful conditions, more trials of these drugs are warranted (recommendation: weak, quality of evidence: low).

Tandospirone 10 mg three times a day may be an efficacious second-line treatment for FD, but there is no evidence that other 5-hydroxytryptamine-1A agonists, including buspirone 10 mg three times a day, are efficacious. However, more trials of these drugs are warranted (recommendation: weak, quality of evidence: low).

Pregabalin 75 mg once daily may be an efficacious second-line treatment for FD but further randomised controlled trials (RCTs) are needed and given its controlled drug status we advise this drug is only used in specialist settings (recommendation: weak, quality of evidence: low).

Mirtazapine 15 mg once daily may be an efficacious second-line treatment for patients with FD with early satiation and weight loss, but further RCTs are needed (recommendation: weak, quality of evidence: very low).

G Mohan.