Sucralfate suspension 1 g four times per day in the short-term treatment of active duodenal ulcer

Treatment of peptic ulcer disease with sucralfate: a review

Sucralfate has been used widely for the treatment of peptic ulcer. Healing rates for duodenal ulcer range from 60 to 90% at 4-6 weeks and up to 90% at 12 weeks for gastric ulcer. The small number of maintenance trials suggest that relapse of duodenal ulcer is reduced comparably to H2 receptor antagonists. There has been considerable interest in the possibility of lower relapse ratios after initial healing with sucralfate compared with H2 receptor antagonists, but more studies of the possible mechanisms as well as larger trials are still needed to confirm these observations.

Why do ulcers heal with sucralfate?

It is unknown why ulcers in general heal. Some clues are worth considering. What is known is (i) that ulcer healing occurs spontaneously, (ii) that ulcers heal more quickly in the duodenum than in the stomach, (iii) that mucosal blood flow at ulcer edge improves with healing, and (iv) that healing can be speeded up by (a) not smoking, (b) removing acid from the stomach, and (c) using non-antisecretory mucosal protective agents such as sucralfate and colloidal bismuth. The difference in healing rates between duodenal and gastric ulcers may be related to ulcer size, duodenal alkalinity due to the secretion of the Brunner's glands, and other uninvestigated factors such as epidermal growth factor and mucosal blood flow. The difference between smokers and non-smokers may be related to inhibition of prostaglandin synthesis and impairment of mucosal blood flow due to smoking and to higher acid secretion in smokers. The success with antisecretory agents indicates that acid inhibits the healing process. The success of sucralfate and bismuth indicates that cytoprotective mechanisms play a role in ulcer healing. The literature also shows that ulcer healing is less affected by smoking in patients treated with sucralfate than in those treated with antisecretory agents, suggesting that cytoprotective mechanisms play a more important part than acid inhibition in counteracting the adverse effects of smoking on healing. Furthermore, ulcer relapse occurs sooner in patients treated with antisecretory agents than in those treated with sucralfate or bismuth, suggesting that withdrawal of antisecretory agents speeds up relapse and/or that cytoprotective mechanisms are associated with longer-lasting remission. It is concluded that sucralfate healing involves cytoprotective mechanisms and that these cannot be ignored in the planning of any anti-ulcer therapy. Despite the understanding of the various site-protective and cytoprotective mechanisms, as discussed in the previous article, it is not clear why ulcers heal with sucralfate. In fact, there is no clear answer to the fundamental question as to why ulcers in general heal with the known therapeutic agents, including H2-receptor antagonists, antacids, proton pump inhibitors, anticholinergics, site-protective agents, and cytoprotective agents. This review examines this question, using sucralfate as a model.

Sucralfate maintenance therapy in duodenal ulcer disease. A review

There are a large number of patients with chronic duodenal ulcer disease who warrant long-term maintenance therapy to diminish the risk of recurrence and thereby the risk of further complications such as gastrointestinal bleeding. The efficacy of sucralfate has been compared with both placebo and histamine (H2)-receptor antagonists and sucralfate in a dose of 1 g twice a day or 2 g taken at night. It is a safe and effective medication in preventing duodenal ulcer recurrence. However, duodenal ulcer relapse rates always exceed 20 percent and frequently approach 50 percent, whether the therapy be H2-receptor antagonists or sucralfate, and the use of dosages that are half the healing dose seems irrational. It would therefore seem reasonable to continue maintenance therapy at the healing dose, whatever medication is used. Any increased costs for drugs should be outweighed by savings in indirect costs.

Implications of sucralfate-induced ulcer healing and relapse

A review of the literature indicates that sucralfate attains a healing rate of 79 percent for duodenal ulcer and 75 percent for gastric ulcer in four and eight weeks, respectively, rates not different from those reported for cimetidine and ranitidine. Meta-analyses show that, whereas cigarette smoking significantly affects duodenal ulcer healing by acid-reducing agents, the healing rates of smokers and non-smokers treated with sucralfate are indistinguishable, suggesting an inherent advantage through the underlying mechanisms of the drug. Pooling reports in the literature indicates that the 12-month relapse curves of duodenal ulcers initially healed with sucralfate and colloidal bismuth subcitrate closely overlap each other and are significantly lower than the curves of the histamine (H2)-receptor antagonists under comparison. A review of the ulcer relapse rates following initial healing in the literature shows that patients receiving acid-reducing agents such as antacids, H2-receptor antagonists, and omeprazole have relapses at similar rates. Use of anticholinergics or non-antisecretory agents including carbenoxolone sodium is associated with a longer remission. Preliminary evidence is available to support the concept that the use of acid-reducing agents results in up-regulation, whereas the use of anticholinergics and non-antisecretory agents is associated with down-regulation of the parietal cells. These changes at the molecular level may help to explain the differences in relapse rates following initial healing with various anti-ulcer agents.