Carafate Dosing for Peptic Ulcer Disease
For active duodenal ulcers, administer sucralfate 1 gram four times daily on an empty stomach (30 minutes before meals and at bedtime) for 4-8 weeks, or alternatively 2 grams twice daily (on waking and at bedtime) for equivalent efficacy with improved convenience. 1
Active Ulcer Treatment Dosing
Standard FDA-Approved Regimen
- 1 gram four times daily taken on an empty stomach (30 minutes before meals and at bedtime) 1
- Continue treatment for 4-8 weeks unless healing is demonstrated earlier by endoscopy or radiography 1
- Antacids may be used for pain relief but must be separated by at least 30 minutes from sucralfate doses 1
Alternative Convenient Regimen
- 2 grams twice daily (on waking and at bedtime) demonstrates equivalent healing rates to the four-times-daily regimen 2, 3
- At 4 weeks: 78-79% healing rate with twice-daily dosing versus 72-74% with four-times-daily dosing 2, 3
- At 8 weeks: cumulative healing rates of 83-85% for both regimens 2, 3
- This simplified dosing may improve adherence while maintaining efficacy 4
Maintenance Therapy Dosing
After ulcer healing, use 1 gram twice daily to prevent recurrence 1
- Alternative maintenance dosing of 2 grams at bedtime may be appropriate for long-term management 4
- Maintenance therapy reduces duodenal ulcer recurrence rates comparably to H2-receptor antagonists 5
Important Context: Sucralfate's Role in Modern PUD Management
Current Treatment Hierarchy
While sucralfate remains FDA-approved and effective for PUD, proton pump inhibitors (PPIs) are recommended as first-line therapy by modern gastroenterology guidelines 6
- Sucralfate serves as an alternative when PPIs are contraindicated or not tolerated 6
- For H. pylori-positive ulcers, eradication therapy must be added regardless of which ulcer-healing agent is used 6, 7
Special Population Where Sucralfate Excels
In critically ill patients requiring stress ulcer prophylaxis, sucralfate demonstrates significant advantages over acid-suppressing agents 8, 6:
- 27% reduction in mortality compared to H2-receptor antagonists (OR 0.73,95% CI 0.54-0.97) 6
- 35% lower likelihood of ventilator-associated pneumonia 6
- Reduced VAP incidence (16.2% vs 19.1%) compared to H2-blockers 6
- These benefits stem from preserving gastric pH, preventing bacterial overgrowth that occurs with acid suppression 6
Maximum Daily Dose
Do not exceed 4 grams total daily (whether given as 1g QID or 2g BID) 8
Practical Considerations
Timing and Administration
- Must be taken on an empty stomach for optimal efficacy 1
- Separate from antacids by at least 30 minutes 1
- May interfere with absorption of other medications requiring acidic environment 9
Elderly Patients
Start at the lower end of the dosing range due to potential decreased hepatic, renal, or cardiac function 1
Common Pitfall
Failure to test for H. pylori leads to 40-50% recurrence rates over 10 years 9