Is there a particular prokinetic agent that you recommend if a patient has failed both PPI and TCA in the treatment of suspected functional dyspepsia?

In general, the evidence to support the use of prokinetics in functional dyspepsia (FD) is not strong. The rationale for using a prokinetic agent for FD is to improve gastric emptying time in the subset (about ¼) of patients who delayed gastric emptying which is usually mild. The three prokinetic agents studied in FD are not available in the US. There is some evidence for domperidone but this is mainly to treat nausea and vomiting if this is present (less typical in FD than in gastroparesis). Itopride and acotiamide have shown some benefit in FD. Prucalopride is a prokinetic agent available in US and other countries but is FDA-approved for chronic idiopathic constipation. It has been shown in a small controlled trial that it can normalize g...

We frequently perform gastric accommodation SPECT which is abnormal in a subset of patients with FD. These patients have particular benefit from buspirone which induces fundal relaxation.

There is little evidence to support the use of prokinetics for FD. I do sometimes use them and typically will use Reglan in low doses or motegrity if someone has concomitant constipation.

There was a SR in 2019 published in the Am J Gastro (Pittayanon et al., PMID 30337705) that suggested prokinetics might help FD but there was a great deal of heterogeneity between studies and most of the examined prokinetics are not available in the US.

More commonly, I will try other neuromodulators or even COM with botanicals rather than prokinetics in patients with FD refractory to PPI and TCA.