Prokinetic Agents for Functional Dyspepsia

Introduction to Prokinetic Therapy

• The British Society of Gastroenterology guidelines recommend prokinetics as the preferred option for patients with postprandial distress syndrome (PDS) subtype, particularly for symptoms of bloating, early satiation, and fullness, with cinitapride, acotiamide, and metoclopramide being the most evidence-supported agents 1

First-Line Prokinetic Options

• For dysmotility-like symptoms, such as fullness, bloating, and early satiety, prokinetics should be used as first-line therapy rather than acid suppression, according to the British Society of Gastroenterology guidelines 1
• The American College of Chest Physicians recognizes cinitapride as effective, particularly when combined with acid suppression for overlapping GERD symptoms, with a favorable safety profile and minimal QT prolongation risk 2

Specific Prokinetic Agents

• Domperidone has a low risk of QT prolongation at usual oral therapeutic doses, though caution is warranted 4
• Prucalopride, a 5-HT4 agonist, shows promise for constipation-predominant symptoms and may reduce GERD severity, though evidence in functional dyspepsia (FD) specifically is emerging 5

Treatment Algorithm

• Identify predominant symptom pattern, and if postprandial fullness, bloating, early satiety predominate, start with prokinetic therapy, as recommended by the British Society of Gastroenterology guidelines 1, 3
• Select appropriate prokinetic based on availability and risk profile, with cinitapride or acotiamide preferred if available due to better safety profiles 2

Critical Safety Considerations

• Avoid prokinetics in patients with gastrointestinal obstruction or perforation, or history of tardive dyskinesia or significant extrapyramidal symptoms, as recommended by the Clinical Gastroenterology and Hepatology guidelines 6

Evidence Quality and Limitations

• Acotiamide and cinitapride have the most favorable evidence-to-safety profiles among currently available prokinetic agents, according to the Praxis Medical Insights guidelines 2