How is Carafate (sucralfate) used to treat stomach ulcers?

Sucralfate (Carafate) for Stomach Ulcers

Sucralfate is effective for treating duodenal ulcers but is not recommended as first-line therapy for stress ulcer prophylaxis due to the availability of superior alternatives like PPIs and H2-receptor antagonists. 1

Mechanism of Action

Sucralfate works through a local, rather than systemic, mechanism:

• Forms an ulcer-adherent complex with proteinaceous exudate at the ulcer site 2
• Creates a protective barrier against acid, pepsin, and bile salts 3
• Minimally absorbed (only 3-5%) with >90% excreted unchanged in feces 3
• Remains at gastric ulcer sites for up to six hours 3
• Has mild acid-neutralizing capacity (14-16 mEq per 1g dose) 2

FDA-Approved Indications

Sucralfate is FDA-approved for:

• Short-term treatment (up to 8 weeks) of active duodenal ulcer
• Maintenance therapy for duodenal ulcer patients at reduced dosage after healing of acute ulcers 2

Efficacy for Different Ulcer Types

Duodenal Ulcers

• Healing rates range from 60-90% at 4-6 weeks 4
• Comparable efficacy to cimetidine and intensive antacid therapy 3

Gastric Ulcers

• Healing rates up to 90% at 12 weeks 4
• Effective for corpus and prepyloric ulcers (80% and 93% healing at 8 weeks, respectively) 5
• Comparable to famotidine (90% vs 75% healing at 8 weeks) 6

Stress Ulcer Prophylaxis

• Not recommended as first-line therapy for stress ulcer prophylaxis 1
• PPIs and H2-receptor antagonists are preferred for stress ulcer prophylaxis 1

Dosing Regimen

• Standard dose: 1g four times daily, one hour before meals and at bedtime 3
• Treatment duration: 4-8 weeks for active ulcers 2
• Can be used at reduced dosage for maintenance therapy after healing 2

Advantages and Limitations

Advantages

• Well-tolerated with minimal systemic absorption 7
• Few drug-drug interactions reported 3
• May be useful in specific situations where acid suppression is contraindicated

Limitations

• Not effective in preventing NSAID-related gastric ulcers 1
• Less convenient dosing schedule (four times daily) compared to once-daily PPIs
• Not recommended for stress ulcer prophylaxis due to superior alternatives 1

Side Effects

• Constipation (most common, 2-4% of patients) 3, 7
• Dry mouth (xerostomia, 1%) 3
• Skin eruptions (0.6%) 3

Special Applications

• Can be used as a topical suspension for oral and genital ulcers in Behçet's disease 1
• May be considered when acid suppression is contraindicated

Clinical Decision Algorithm

1. For duodenal ulcers:

   • Consider sucralfate 1g four times daily for 4-8 weeks
   • Continue until healing is confirmed by endoscopy or X-ray
   • Consider maintenance therapy at reduced dosage after healing

2. For stress ulcer prophylaxis:

   • Choose PPIs or H2-receptor antagonists as first-line therapy 1
   • Reserve sucralfate as a second-line agent only when first-line options are contraindicated 1

3. For NSAID-related gastric ulcers:

   • Do not use sucralfate as it is not effective for prevention 1
   • Choose PPIs instead 1

Common Pitfalls

• Using sucralfate for stress ulcer prophylaxis as first-line therapy when PPIs or H2-receptor antagonists are more effective
• Expecting sucralfate to prevent NSAID-related gastric ulcers
• Inadequate dosing frequency (requires four times daily administration)
• Not administering on an empty stomach (should be given 1 hour before meals)
• Forgetting that sucralfate may bind to other medications, potentially reducing their absorption