The most appropriate management is to start nortriptyline. This patient has functional dyspepsia (FD), a chronic symptom complex consisting of epigastric pain/discomfort, postprandial fullness, and/or early satiety in the absence of a structural explanation. No universally effective therapy exists, but a variety of treatments are effective in subgroups of FD. Treatment strategies must carefully weigh the therapeutic benefits with the side effects of therapy. Given the low risk of side effects, initial treatment strategies include treatment of Helicobacter pylori infection, proton pump inhibitor (PPI) therapy, or H2-blocker therapy. Although generally well tolerated, these treatment strategies frequently fail to adequately alleviate symptoms. In particular, treatment for H. pylori is unlikely to be beneficial in this patient with negative test results. Clinical trials have not demonstrated an added benefit of high-dose PPI therapy compared with standard-dose therapy. Therefore, increasing omeprazole to twice daily would not be beneficial for this patient. Additionally, switching from PPI to H2-blocker therapy is of little benefit given these agents' similar physiologic effect on gastric acid production. Tricyclic antidepressants (TCA) are generally well tolerated, with response rates as high as 70% in small, marginal-quality trials. Despite these limitations, the efficacy and side-effect profile make a trial of a low-dose TCA such as nortriptyline an attractive treatment strategy when symptoms do not respond to PPIs or H2 blockers. Therefore, nortriptyline is the most appropriate management.
Narcotics such as hydrocodone have no role in the treatment of FD and are likely to promote side effects as well as dependence.
The prokinetic agent metoclopramide has demonstrated limited efficacy. The benefits of its use should be weighed against the substantial risk of potential neurologic side effects, which include akathisia (nervousness, restlessness, anxiety, agitation), parkinsonism (bradykinesia, resting tremor, and rigidity), and tardive dyskinesia (involuntary, repetitive, tic-like movements that involve primarily the facial muscles but also the extremities, digits, hips, or torso).