**6. Alternative medications and emerging therapies**

Due to high therapy failure and risk of drug side effects from FD treatment, alternative medicine is attractive. Alternative medicine includes herbal medicine, traditional Chinese medicine and the emerging therapies, especially invasive procedures for gastroparesis.

STW 5 (also known as Iberogast) is one of the most studied mixtures of herbs proven to be effective in relieving dyspeptic symptoms. The main and active ingredient of STW 5 is *Iberis amara*, which acts both to reduce acid secretion and accelerate gastric emptying [77]. The last action is a result of its different effects on gastric portions, inhibiting the proximal portion of the stomach while exciting the tonus of the distal stomach [78]. Its prokinetic action is similar to cisapride [79]. Usual dosage of STW 5 is 20 drops three times a day. Data on other alternative medications are limited, such as artichoke leaf extract, blend of peppermint oil and caraway oil, banana powder capsules, and antioxidant astaxanthin [80].

Less available in other cultures, Xiaoban Xiatang and Zhizhu Tang are the two herbal infusions most used by traditional Chinese physicians to treat dyspeptic symptoms [81]. However, regarding traditional Chinese medicine, acupuncture is undoubtedly the procedure that deserves most attention. It has been shown that acupuncture accelerates gastric emptying time and reduces postprandial fullness, early satiety and bloating [82].

Among emerging therapies for gastroparesis, there are invasive procedures like gastric electrical stimulation and pyloric botulinum toxin injection. Gastric electrical stimulation consists of surgical implantation of electrodes into the muscle layer of the gastric antrum. A pulse generator in the abdominal wall delivers low-energy electrical pulses at high frequency to the electrodes. Meta-analyses have shown benefits of this technique, and isolated studies have demonstrated improvement of dyspeptic symptoms, quality of life, weight, body mass index and albumin level [83-86]. Gastric electrical stimulation seems to work less because of its motor effects on gastric motility, and more because of its effects in altering the sensory function of afferent nerves of the stomach. Surgical complications occur in 10% of cases, indicating that this method should be prescribed only for refractory cases and not as routine therapy. Another invasive procedure for gastroparesis is the injection of the botulinum toxin (botox) in a circumferential manner into the pyloris. Due to its effect of inhibiting acetylcholine release, botox accelerates gastric emptying and improves dyspeptic symptoms in open-label trials [87-89]. The procedure consists of intrapyloric injection of 100-200 units of botox during endoscopy and has been proven to be safe. However, botox injection cannot be currently recommended since at least two double-blind placebo controlled studies showed the same effects of botox and placebo [90,91]. Table 7 summarizes the treatment options for FD.


**Table 7.** Treatment options for functional dyspepsia

Among the peculiarities of FD in ESRD patients, there is the extensive list of stressors associated with HD: illness effects, dietary constraints, time restriction, functional limitations, changes in employment, sexual dysfunction, and high mortality [13]. This explains why depression and anxiety are highly prevalent among HD patients [9,11]. Anxiety and depression can be manifested by dyspepsia (somatization). This fact forces the inclusion of depression in the differential diagnosis of FD alongside gallbladder, pancreatitis, medications, and hepatobiliary causes. On the other hand, dyspeptic symptoms of FD are more likely to be severe in depressive patients. There are several studies showing benefits of anxiolytics and antidepressants, especially tricyclic antidepressants, in the relief of dyspeptic symptoms, although their results are not superior to those of PPIs or prokinetics in the general population [72]. Once again, we have to be careful to extrapolate these population data to specific samples of ESRD patients. Due to the previously reported list of associated stressors and high prevalence of depression among HD patients, it is plausible that the effects of antidepressants can be more pronounced among HD patients than in the general population. Taking two specific drugs: amitriptyline (tricyclic antidepressant) and sertroline (selective serotonin reuptake inhibitor antidepressant) can be effective. Amitriptyline ameliorates dyspeptic symptoms in subjects who did not obtain relief with antacids and prokinetics [73]. Sertroline is a very attractive drug to test for FD in HD patients because of its additional effect of decreasing the serum level of interleukin-6 in HD patients on HD [74]. However, treatment of depression among HD patients is not simple. Drug therapy alone for depression has proven to be ineffective among HD patients. One of the reasons is that drug therapy by itself cannot eliminate the powerful stressors associated with HD therapy. For instance, among women undergoing HD, the sole use of drugs for depression will fail if there is not a concurrent approach to sexual dysfunction [75]. To my thinking, it is clear that treatment of FD in HD patients should include screening for depressive symptoms, and if depression exists, psychotherapy is necessary along with the use of drugs. Supporting this opinion, psychotherapy was proved to be beneficial for FD in controlled

random trials [76].

102 Updates in Hemodialysis

**6. Alternative medications and emerging therapies**

oil, banana powder capsules, and antioxidant astaxanthin [80].

Due to high therapy failure and risk of drug side effects from FD treatment, alternative medicine is attractive. Alternative medicine includes herbal medicine, traditional Chinese medicine and the emerging therapies, especially invasive procedures for gastroparesis.

STW 5 (also known as Iberogast) is one of the most studied mixtures of herbs proven to be effective in relieving dyspeptic symptoms. The main and active ingredient of STW 5 is *Iberis amara*, which acts both to reduce acid secretion and accelerate gastric emptying [77]. The last action is a result of its different effects on gastric portions, inhibiting the proximal portion of the stomach while exciting the tonus of the distal stomach [78]. Its prokinetic action is similar to cisapride [79]. Usual dosage of STW 5 is 20 drops three times a day. Data on other alternative medications are limited, such as artichoke leaf extract, blend of peppermint oil and caraway
