Carafate (Sucralfate) Dosing
For adults with active duodenal or gastric ulcers, the standard dose is 1 gram four times daily taken 1 hour before meals and at bedtime, though a simplified regimen of 2 grams twice daily (upon waking and at bedtime) is equally effective and may improve adherence. 1, 2
Standard Adult Dosing Regimens
Active Ulcer Treatment
Option 1 (Traditional):
- 1 gram four times daily
- Timing: 30-60 minutes before breakfast, lunch, dinner, and at bedtime
- Duration: Up to 8 weeks for duodenal ulcers 1, 3
Option 2 (Simplified, Equally Effective):
- 2 grams twice daily
- Timing: Upon waking and at bedtime
- This regimen achieves comparable healing rates (78-83% at 4 weeks, 83-92% at 8 weeks) to the four-times-daily schedule 2, 4, 5
- The twice-daily regimen is preferred for improved compliance without sacrificing efficacy 2, 4
Maintenance Therapy
- 2 grams daily for prophylaxis against duodenal ulcer recurrence 3
Pediatric Dosing
No specific pediatric dosing guidelines for oral sucralfate tablets are established in the provided evidence. The American Academy of Pediatrics advises avoiding commercially available liquid preparations in neonates due to hyperosmolar sorbitol content; hospital pharmacies should prepare sorbitol-free formulations for neonatal use 6
Special Formulations
Sucralfate Enemas (Radiation Proctitis)
- Dose: 2 grams mixed with 30-50 mL water
- Initial frequency: Twice daily
- Maintenance: May reduce to once daily after symptom stabilization
- Administration technique: Patient should roll through 360 degrees to coat entire rectal surface, retain for at least 20 minutes 6
Critical Administration Requirements
Timing Relative to Other Medications
Sucralfate requires an acidic environment to work effectively. Separate administration from acid-suppressing medications (PPIs, H2-blockers) by at least 2 hours to avoid reduced efficacy 6. Similarly, administer ketoconazole at least 2 hours before sucralfate 6
Formulation Details
- Tablets: 1 gram (standard formulation) 1
- Mechanism requires acidic pH: Sucralfate binds to proteinaceous material at ulcer sites and forms a protective barrier, but this process is pH-dependent 1
Important Limitations and Contraindications
When NOT to Use Sucralfate
NSAID-induced gastric ulcers: PPIs are strongly preferred over sucralfate for this indication 6
Radiation-induced conditions where sucralfate is NOT effective:
- Oral mucositis (in patients receiving chemotherapy or radiation) 6
- Acute radiation-induced diarrhea 6
- Gastrointestinal mucositis from radiation 6
Stress Ulcer Prophylaxis Context
While sucralfate has been studied for stress ulcer prophylaxis, PPIs or H2-blockers are now preferred agents 7. The 2012 Surviving Sepsis Campaign guidelines recommend against using sucralfate as a first-line agent, noting that acid suppression with PPIs is preferred 7
Pharmacokinetics and Safety
- Absorption: Only 3-5% absorbed systemically; >90% excreted unchanged in feces 1
- Duration at ulcer site: Remains at gastric ulcer sites for up to 6 hours 1
- Most common side effect: Constipation (2-4% of patients) 1, 3
- Other minor effects: Dry mouth (1%), skin eruptions (0.6%) 1
Clinical Efficacy Context
Sucralfate demonstrates comparable efficacy to cimetidine and intensive antacid therapy for duodenal ulcers, with healing rates of 72-79% at 4 weeks and 80-85% at 8 weeks 2, 4. For gastric ulcers, healing rates are 59-67% at 8 weeks and 71-92% at 12 weeks, also comparable to H2-blockers 5. However, PPIs have largely superseded sucralfate as first-line therapy due to superior acid suppression and proven superiority in preventing NSAID-related ulcers 7.