Carafate (Sucralfate) for Stomach and Duodenal Ulcers
Carafate (sucralfate) is FDA-approved only for duodenal ulcers, not gastric ulcers, and should be considered a second-line agent since proton pump inhibitors (PPIs) are the preferred first-line treatment for all peptic ulcers. 1, 2
When to Use Carafate
Carafate is appropriate as an alternative when PPIs are contraindicated, not tolerated, or as add-on therapy for refractory duodenal ulcers. 1 The drug is specifically indicated for:
- Short-term treatment (up to 8 weeks) of active duodenal ulcer 2
- Maintenance therapy for duodenal ulcer patients at reduced dosage after healing of acute ulcers 2
Carafate is NOT effective for NSAID-related gastric ulcers—PPIs remain the preferred treatment for this indication. 1
Dosing Regimen for Active Duodenal Ulcers
The standard FDA-approved dose is 1 gram four times daily, taken 1 hour before meals and at bedtime, for 4 to 8 weeks. 2
- An alternative simplified regimen of 2 grams twice daily (on waking and at bedtime) is equally effective and may improve compliance. 3
- Treatment should continue for the full 4 to 8 weeks even if healing occurs earlier, unless confirmed by endoscopy. 2
- Healing rates with sucralfate are 75-92% at 4 weeks and 76-85% at 8 weeks. 2, 4, 5
Dosing for Maintenance Therapy
After healing, maintenance therapy with 1 gram twice daily significantly reduces duodenal ulcer recurrence. 2 At 12 months, recurrence rates are 27% with sucralfate versus 65% with placebo. 2
Critical Drug Interactions and Timing
Sucralfate must be administered at least 2 hours apart from PPIs or H2-blockers to avoid interaction, as these acid-suppressing drugs can interfere with sucralfate's mechanism of action. 1 Sucralfate works by forming a protective barrier at the ulcer site in an acidic environment, so reducing gastric acidity impairs its effectiveness. 2
Essential Concurrent Management
For H. pylori-associated ulcers, eradication therapy MUST be added to sucralfate treatment. 1 Failure to eradicate H. pylori increases recurrence rates to 40-50% over 10 years. 6
For NSAID-induced duodenal ulcers, discontinue NSAIDs immediately if possible. 1, 6 If NSAIDs cannot be stopped, switch to a PPI-based regimen rather than relying on sucralfate alone. 6
Why PPIs Are Preferred First-Line
PPIs achieve superior healing rates (95-98% for duodenal ulcers at 4-6 weeks, 94-96% for gastric ulcers at 8 weeks) compared to sucralfate. 7 The American College of Gastroenterology and American Gastroenterological Association both recommend PPIs as first-line therapy, with sucralfate relegated to second-line status. 7, 1
Mechanism and Safety Profile
Sucralfate works locally by forming an ulcer-adherent complex that protects the ulcer site from acid, pepsin, and bile salts. 2 It is minimally absorbed (only 3-5%), making it extremely well-tolerated with constipation being the most common side effect (2-4% of patients). 2, 8, 9
Common Pitfalls to Avoid
- Do not use sucralfate for gastric ulcers—it lacks FDA approval and efficacy data for this indication 2
- Do not use sucralfate for NSAID-related gastric ulcers—PPIs are required 1
- Do not co-administer sucralfate with PPIs or H2-blockers without a 2-hour separation 1
- Do not forget to test for H. pylori and provide eradication therapy when positive 1, 6
- Do not stop treatment prematurely—complete the full 4-8 week course 2