In an adult patient with a peptic ulcer, which is preferable: rebamipide (Mucosta) or sucralfate?

Rebamipide (Mucosta) vs Sucralfate for Peptic Ulcer Disease

For adult patients with peptic ulcers, neither rebamipide (Mucosta) nor sucralfate should be used as first-line therapy—proton pump inhibitors (PPIs) are the clearly superior choice. However, if you must choose between these two agents, rebamipide appears to offer advantages in quality of ulcer healing and mucosal protection mechanisms, though sucralfate has more extensive clinical validation in Western guidelines. 1, 2

Primary Treatment Recommendation

PPIs (such as omeprazole 20 mg once daily) are the first-line treatment for peptic ulcer disease, with H2-receptor antagonists as acceptable alternatives. 1 The American College of Cardiology explicitly states that sucralfate is "not recommended for gastric ulcer prevention or treatment due to availability of far superior alternatives (PPIs)." 1, 2

When Sucralfate Should Be Considered

Sucralfate is relegated to second-line status only when PPIs or H2-blockers cannot be used due to contraindications or intolerance. 1

Clinical Efficacy of Sucralfate

• Healing rates for duodenal ulcers range from 60-90% at 4-6 weeks, comparable to cimetidine and intensive antacid therapy. 3, 4
• Gastric ulcer healing rates are "less impressive" but still comparable to H2-antagonists. 3
• Maintenance therapy at 2g nightly reduces duodenal ulcer recurrence rates. 5, 6

Mechanism and Administration

• Forms a protective barrier at ulcer sites, inhibits pepsin action, and adsorbs bile salts without significantly affecting gastric pH. 3, 4
• Must be administered at least 2 hours apart from PPIs or H2-blockers to avoid interaction. 1, 7
• Standard dosing: 1g four times daily, one hour before meals and at bedtime. 3

Rebamipide (Mucosta) Characteristics

Potential Advantages

Rebamipide offers unique mechanisms that may improve quality of ulcer healing rather than just speed:

• Stimulates prostaglandin generation and increases gastric mucus glycoprotein components. 8
• Enhances epithelial cell migration and proliferation at wound sites. 8
• Scavenges active oxygen radicals and attenuates neutrophil activity. 8
• May reduce inflammatory responses in H. pylori-infected patients and potentially enhance eradication therapy. 8

Critical Limitation

Rebamipide is not mentioned in any Western guidelines (WSES, American College of Cardiology, American College of Gastroenterology) for peptic ulcer management. 9, 1, 2 It is approved in Japan but lacks the extensive validation in international consensus statements that sucralfate possesses.

Special Clinical Scenarios

H. pylori-Positive Patients

Test and treat for H. pylori first with standard triple therapy (amoxicillin, clarithromycin, and PPI) if low clarithromycin resistance is present. 9 Neither sucralfate nor rebamipide should replace appropriate eradication therapy.

NSAID-Related Ulcers

Sucralfate is NOT effective for NSAID-related ulcers—discontinue NSAIDs if possible and use PPIs instead. 1 The American Heart Association explicitly recommends against sucralfate in this setting.

Critical Care/Stress Ulcer Prophylaxis

Sucralfate may be preferred in mechanically ventilated patients due to lower ventilator-associated pneumonia risk compared to acid-suppressive therapy, though it carries higher gastrointestinal bleeding rates. 1, 7, 2

Common Pitfalls to Avoid

• Do not use sucralfate concurrently with PPIs or H2-blockers without proper spacing (minimum 2 hours apart). 1, 7
• Do not choose sucralfate over PPIs for routine peptic ulcer treatment—this represents suboptimal care. 1, 2
• Do not assume rebamipide is equivalent to standard therapy based solely on its interesting mechanisms—it lacks guideline support in Western medicine. 8
• Constipation occurs in 2-4% of sucralfate patients, which may be problematic in certain populations. 3, 4