Functional Dyspepsia - A Revolution in Management
Functional Dyspepsia - A Revolution in Management
复制标题
功能性消化不良——管理革命
DOI：
10.1038/s41395-018-0264-8
复制
发表时间：
2018
影响因子：
9.8
通讯作者：
Miwa H
中科院分区：
文献类型：
--
作者：
Oshima T;Miwa H
抑酸药物包括质子泵抑制剂（PPI）和促动力剂已被推荐为FD的一线治疗。在最近的一项荟萃分析中，PPI比促动力剂稍有效[14]。FD和对照组之间胃酸分泌功能无差异，但FD患者发生十二指肠酸化，FD患者胃或十二指肠酸给药产生的症状比对照组更严重[15，16]。此外，PPI的抗炎作用也可能预防轻度十二指肠炎症。抑酸药物治疗EPS和促动力剂治疗PDS症状的概念[2]在日本被接受用于治疗FD。为了促进FD治疗，现在还考虑将抑酸药物与促动力剂联合给药。然而，证据仍然有限，这种方法可能不具有成本效益。指南的差异包括三环类抗抑郁药（TCA）和促动力剂在FD治疗中的地位[3，4]。在ACG和CAG指南中，TCA是PPI之后的下一个治疗选择[3]。支持促动力剂的证据仅限于西沙必利，该药物因心脏副作用而被撤回。在日本，阿考替胺现已上市，最近在欧洲也进行了评估，在III期研究中证实了其长期安全性[17]。阿考替胺通过抑制乙酰胆碱酯酶和拮抗胆碱能神经末梢上抑制性毒蕈碱1型和2型受体，对胃底松弛和胃动力特性产生影响。这种药物影响与膳食相关的消化不良症状（餐后饱胀、上腹部腹胀和早饱），但不影响上腹痛[18]。在上述III期研究中，阿考替胺的耐受性良好，不良事件的发生率在阿考替胺和安慰剂组之间相似。
Acid-suppressing drugs including proton pump inhibitors (PPIs) and prokinetics have been recommended as the first-line therapies for FD. In a recent meta-analysis, PPIs were slightly more effective than prokinetics [14]. Gastric acid secretion function did not differ between FD and controls, but duodenal acidification occurs in FD and administration of acid into the stomach or duodenum in FD produced more severe symptoms than in controls [15, 16]. Furthermore, anti-inflammatory effects of PPIs might also prevent low-grade duodenal inflammation. The concept of acidsuppressive drugs for EPS and prokinetics for PDS symptoms [2] is accepted for the treatment of FD in Japan. To facilitate FD treatment, administration of acid-suppressive drugs in combination with prokinetics is also now considered. However, the evidence remains limited, and this approach may not be cost-effective. Differences in guidelines include the positions of tricyclic antidepressants (TCAs) and prokinetics in the treatment of FD [3, 4]. TCA is the next treatment option after PPI in ACG and CAG guidelines [3]. Evidence in favor of prokinetics had been limited to cisapride, which was withdrawn due to cardiac side effects. InJapan, acotiamide is now available and was also recently evaluated in Europe, where long-term safety was confirmed in a phase III study [17]. Acotiamide has effects on fundus relaxation and gastroprokinetic properties by inhibiting acetylcholinesterase and by antagonizing the inhibitory muscarinic type 1 and type 2 receptors on cholinergic nerve endings. This drug affects meal-related dyspeptic symptoms (postprandial fullness, upper abdominal bloating and early satiation), but not epigastric pain [18]. Acotiamide was well tolerated and the incidences of adverse events were similar between acotiamide and placebo groups in the aforementioned phase III study.