<h2>Practice points</h2><ul><li>STW-5 is an evidence-based herbal combination indicated for treating functional dyspepsia and irritable bowel syndrome. Its efficacy has been demonstrated in several clinical studies5</li><li>The efficacy of STW-5 has been linked to the mechanisms of action of the nine herbal extracts it contains5</li><li>Digestive enzymes such as proteases, amylases and lipases may play a role in the treatment of dyspepsia through their role in improving digestion6. They help to break down various food types into smaller units which are easier to digest6</li></ul><h2>Description</h2><ul><li>Functional dyspepsia is one of a number of disorders coming under the umbrella term of functional gastrointestinal disorders (FGIDs)1</li><li>FGIDs are a collection of disorders that affect various parts of the gastrointestinal system and share a number of features - their underlying pathophysiology is largely unknown, they are not caused by an anatomical (structural) or traumatic defect, and they have symptoms that are often vague1</li><li>Dyspepsia is a very common gastrointestinal symptom, although the incidence varies by age, sex, ethnicity and geographical region</li><li>Functional dyspepsia is defined as dyspepsia that is not associated with structural defects such as gastric or peptic ulcers1</li><li>Functional dyspepsia is the most common cause of dyspeptic symptoms in the West and increasingly in other parts of the world. The symptoms include upper abdominal pain or discomfort with or without other upper gastrointestinal symptoms such as nausea, belching and vomiting. Other symptoms can include a feeling of being bloated after meals and early satiation2</li></ul>

<h2>Management principles</h2><ul><li>Treatment of indigestion falls into two broad categories - a change in lifestyle and the possible use of medications to help with symptoms3</li><li>In patients with mild or intermittent symptoms, reassurance and lifestyle advice may be sufficient3. Lifestyle advice may include avoiding trigger foods, having small regular meals, chewing food sufficiently and not rushing meals2</li><li>In terms of conventional medicinal treatment, Helicobacter pylori (H. pylori) infection should always be treated with an appropriate antibiotic regime</li><li>In those with severe symptoms or who have been unresponsive to lifestyle changes or H.pylori eradication treatment (where warranted), proton pump inhibitors (PPIs) and prokinetics may be useful. PPIs are used in the presence of retrosternal or epigastric burning or epigastric pain. Prokinetics are used in dyspepsia with early satiation or postprandial fullness3</li><li>H2-receptor antagonists can be used as an alternative to PPIs, however there is some evidence to suggest that PPIs are more effective4</li></ul>

Management

<h2>Primary recommendations</h2><h2>STW-5</h2>Mechanism of action<ul><li>STW-5 is a blend of nine different herbs: bitter candytuft, angelica, chamomile, caraway, St Mary’s thistle (milk thistle), lemon balm, peppermint, greater celandine and liquorice5</li><li> These herbs have distinct effects on the gastrointestinal tract, with each having different mechanisms of action5</li><li> The mechanisms by which the single herbs exert their action include modulation and reduction of gastric acid secretion, anti-inflammatory actions throughout the gastrointestinal tract, mucosal protection, and regulation of gastrointestinal motility5</li></ul>Dosage information<ul><li>Adults: 20 drops three times daily.</li><li>Children 6-12 yrs: 15 drops three times daily. </li><li>Children 3-6 yrs: 10 drops three times daily. </li><li>Children 3 mths-3 yrs: 8 drops three times daily. </li><li> Infants under 3 mths: 6 drops three times daily.</li></ul>Adverse effectsThe safety profile of STW-5 has been extensively evaluated in pre-clinical, controlled and non-interventional or retrospective clinical studies.10 These studies have shown the incidence of adverse drug reactions to be 0.04%. No serious adverse drug reactions were identified.Key interactionsRefer to the Complementary Medicine Interactions Guide: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a><h2>DIGESTIVE ENZYMES</h2>Mechanism of action<ul><li> A transient deficiency of digestive enzymes is one of the causes of functional dyspepsia, with a reduction in primary digestive enzymes including proteases, amylases and lipases6. </li><li>There are a number of digestive enzymes that can play a role in improving digestion, all with different actions. These include:</li><li><ul><li><ul><li>Amylases break down polysaccharides (carbohydrates)11</li><li>Proteases break down, or hydrolyse, the peptide bonds that join amino acids together to form proteins12</li><li>Cellulases break down plant fibres. The human body does not produce cellulase so cellulose passes through the digestive system unchanged and does not, provide any nutritional value13</li><li>Lipases help to digest fat in the small intestine14</li><li>Lactase, where Tilactase is the Australian approved name for lactase, is involved in the breakdown of lactose to glucose and galactose13</li><li>Bromelain is the general name for the family of proteolytic enzymes from the pineapple fruit and stem. It is commonly used as a supplement to aid digestion of protein15</li></ul></li></ul></li><li>Dosage information</li><li>Varies according to the combination of digestive enzymes in a product.</li><li>Adverse effects</li><li>Bromelain has been used in numerous clinical trials, with minimal side effects. Orally, it can cause gastrointestinal disturbances including diarrhoea, nausea, vomiting and abdominal pain.16</li><li>Lipases taken in large amounts with other pancreatic enzymes can cause diarrhoea, flatulence, abdominal pain and nausea.17</li><li>Key interactions</li><li>Refer to the Complementary Medicine Interactions Guide: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a></li></ul>

Primary

<h2>Diet and lifestyle recommendations </h2><ul><li>Avoid eating trigger foods such as fatty and spicy foods, along with carbonated drinks, as they can cause symptoms in people with functional dyspepsia.7</li><li>Eat five or six small meals a day instead of three large meals.8</li><li>Reduce or eliminate intake of alcohol and caffeine.8</li><li>If possible, avoid certain analgesics, such as aspirin, ibuprofen and naproxen.8</li><li>Control stress and anxiety - mindfulness meditation could be an option.8</li><li>Maintain a healthy weight as excess weight can put pressure on the stomach and cause symptoms.8</li><li>Exercise regularly to maintain a healthy weight and to promote better digestion.8</li></ul>

Diet & lifestyle

<h2>References</h2> 1. Mapel D. Functional disorders of the gastrointestinal tract: Cost effectiveness review. Best Practice &amp; Research Clinical Gastroenterology. 2013;2 (6):913-931. 
 2. Madisch, Ahmed et al. “The Diagnosis and Treatment of Functional Dyspepsia” Deutsches Arzteblatt international vol. 115,13 (2018):222-232.
 3. Camilleri M, Stanghellini V. Current management strategies and emerging treatments for functional dyspepsia. Nature Reviews Gastroenterology &amp; Hepatology. 2013;10(3):187-194.
 4. Sakaguchi M. Comparison of PPIs and H2-receptor antagonists plus prokinetics for dysmotility-like dyspepsia. World Journal of Gastroenterology. 2012;18(13):1517.
 5. Allescher H, Abdel-Aziz H. Mechanism of Action of STW 5 in Functional Dyspepsia and IBS: The Origin of Multi-Target. Digestive Diseases. 2017;35(1):18 24.
 6. Swami OC, et al. Functional dyspepsia and the role of digestive enzyme supplement in its therapy. Int J Basic Clin Pharmacol. 2017 May;6(5):1035- 1041.
 7. Göktaş Z, et al. Nutritional habits in functional dyspepsia and its subgroups: a comparative study. Scandinavian Journal of Gastroenterology. 2016;51(8):903-907.
 8. Indigestion - Symptoms and causes [Internet]. Mayo Clinic. 2018 [cited 6 December 2018]. Available from: <a href="https://www.mayoclinic.org/diseases- conditions/indigestion/ symptoms-causes/syc-20352211.">https://www.mayoclinic.org/diseases- conditions/indigestion/symptoms-causes/syc-20352211.</a>
 9. Rakel D. Integrative medicine. 4th ed. Philadelphia: Elsevier; 2018:429.
 10. Ottillinger B, et al. STW 5 (Iberogast®)—a safe and effective standard in the treatment of functional gastrointestinal disorders. Wiener Medizinische Wochenschrift. 2012;163(3-4):65-72.
 11. Reynolds J. Martindale the Extra Pharmacopeia. 29th ed. London: The Pharmaceutical; 1989:1042.
 12. Venes D, Taber C. Taber’s cyclopedic medical dictionary. 19th ed. Philadelphia: F.A.Davis Company; 2001.
 13. Complementary Medicines Evaluation Committee, Department of Health and Ageing, Australian Government. CMEC 47 Extracted Ratified Minutes. Melbourne: Australian Government; 2004.
 14. Natural Medicines: Lipase-Professional Monograph. Natural Medicines Database 2018.
 15. Roxas M. The role of enzyme supplementation in digestive disorders. Altern Med Rev. 2008 Dec;13(4):307-14.
 16. Natural Medicines: Bromelain-Professional Monograph. Naturalmedicines.therapeuticresearch.com. 2018 [cited 6 December 2018].
 17. Natural Medicines: Lipase-Professional Monograph. Natural Medicines Database 2018.

Functional dyspepsia

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