What is the recommended total daily dose of sucralfate for an adult with peptic ulcer disease and for stress‑ulcer prophylaxis in critically ill patients?

Recommended Daily Dose of Sucralfate

For peptic ulcer disease, administer sucralfate 1 gram four times daily (total 4 grams per day), taken one hour before meals and at bedtime, for 4-8 weeks. 1, 2 For stress ulcer prophylaxis in critically ill patients, use low-dose sucralfate defined as ≤4 grams per day. 3

Peptic Ulcer Disease Dosing

Standard Regimen

• Primary recommendation: 1 gram four times daily (total 4 grams/day), administered one hour before meals and at bedtime 1, 2
• Treatment duration: 4-8 weeks for acute ulcer healing 1
• This dosing schedule has demonstrated duodenal ulcer healing rates of 72-79% at 4 weeks and 80-85% at 8 weeks 4

Alternative Convenient Regimen

• 2 grams twice daily (total 4 grams/day), taken on waking and at bedtime, shows equivalent efficacy to the four-times-daily regimen 5, 4, 6
• This simplified schedule may improve adherence while maintaining healing rates of 78-83% at 4 weeks and 83-85% at 8 weeks 4, 6
• The twice-daily regimen is particularly useful for patients who struggle with medication compliance 5

Maintenance Therapy

• 2 grams once daily at bedtime for long-term management and prevention of ulcer recurrence 5
• This prophylactic dose decreases duodenal ulcer recurrence rates 1

Stress Ulcer Prophylaxis in Critically Ill Patients

Dosing Guidelines

• Maximum dose: ≤4 grams per day as defined by the 2024 Society of Critical Care Medicine guidelines 3
• Typical regimen: 1 gram four times daily or 2 grams twice daily (not to exceed 4 grams total) 3

Important Context for ICU Use

• Sucralfate is NOT recommended as first-line therapy for stress ulcer prophylaxis in critically ill patients 3
• PPIs or H2-receptor antagonists are preferred first-line agents (conditional recommendation, moderate certainty) 3
• However, sucralfate demonstrates a significant mortality advantage over H2-receptor antagonists (OR 0.73,95% CI 0.54-0.97) and reduces ventilator-associated pneumonia risk by 35% 3, 7

When to Consider Sucralfate in ICU Settings

• Patients at high risk for ventilator-associated pneumonia where avoiding gastric pH elevation is critical 3, 7
• The pneumonia benefit stems from sucralfate's lack of effect on gastric pH, preventing bacterial overgrowth that occurs with acid-suppressing agents 3, 7
• Sucralfate shows lower pneumonia rates (16.2%) compared to H2-receptor antagonists (19.1%) 3, 7

Critical Dosing Considerations

Maximum Daily Dose

• Never exceed 4 grams per day in any clinical setting 3, 1, 2
• The 4-gram ceiling applies to both peptic ulcer treatment and stress ulcer prophylaxis 3

Timing and Administration

• Administer one hour before meals when using the four-times-daily regimen to maximize ulcer site contact 1, 2
• Sucralfate remains at gastric ulcer sites for up to 6 hours after administration 2
• Avoid concurrent administration with acid suppressants (PPIs or H2RAs) as no evidence supports additive benefit 3

Common Pitfalls to Avoid

• Do not combine sucralfate with PPIs or H2RAs for stress ulcer prophylaxis—no evidence supports concurrent use and it may increase adverse effects 3
• Do not use sucralfate as monotherapy for H. pylori-associated ulcers; add appropriate eradication therapy 7
• Constipation occurs in 2-4% of patients and is the most common side effect 1, 2
• Only 3-5% of sucralfate is systemically absorbed, with >90% excreted unchanged in feces, making it extremely well-tolerated 2

Special Populations

• For patients requiring long-term ulcer prevention, the 2-gram nightly maintenance dose is appropriate 5
• Smoking does not adversely affect healing in sucralfate-treated duodenal ulcer patients 5
• In critically ill patients with risk factors for stress-related upper GI bleeding, consider sucralfate specifically when pneumonia risk outweighs bleeding risk 3, 7