Drug Approvals
(British Approved Name, US Adopted Name, rINN)
Synonyms: Sucralfato; Sucralfatum; Sukralfaatti; SukralfatPharmacopoeias. In China, Japan, and US.
The United States Pharmacopeia 31, 2008 (Sucralfate). The hydrous basic aluminium salt of sucrose octasulfate. Store in airtight containers.
What is Sucralfate?
Sucralfate is a basic nonabsorbable aluminum salt of sucrose octasulfate. Despite weak antacid properties, the protective effect of sucralfate is not mediated by acid suppression or neutralization, but by a mucosal protective effect on the gastric mucosa. The mucosal protection afforded by sucralfate is mediated by several mechanisms, including formation of a protective barrier, stimulation of gastric mucosal blood flow, prostaglandin-mediated increase in mucus and bicarbonate secretion, and by the stimulation of a variety of growth factors that have been implicated in ulcer healing.
Despite this theoretical benefit, the role of sucralfatein the prophylaxis of clinically significant stress-related erosive syndrome hemorrhage is controversial. Although some studies suggest that sucralfate is an effective prophylactic agent with a benign side effect profile that possibly includes a lower incidence of nosocomial pneumonia, in many of the studies reviewed, sucralfate was not statistically superior to the control group in preventing stress-related erosive syndrome hemorrhage.
In a large study by Cook and colleagues (1998), including 1,200 mechanically ventilated patients, sucralfate was inferior to ranitidine in the prevention of upper gastrointestinal bleeding, and there was no significant differences in the rates of ventilator-associated pneumonia between the two agents. Sucralfate (Carafate) is available as tablets or as liquid slurry that is administered 1 g orally or by nasogastric tube every 4 to 6 hours. Although usually well tolerated, constipation occurs in 2 to 4% of patients receiving sucralfate, and aluminum toxicity has occurred in patients with chronic renal failure.
Despite some theoretical advantages of sucralfate, including its ease of use, lack of need for monitoring, lack of need for supplemental antacid therapy, and cost effectiveness, this agent cannot be recommended as the drug of choice in stress-related erosive syndrome because of discordant study results.
Prostaglandin Analogues
Despite the promise demonstrated in earlier trials, synthetic prostaglandin derivatives, such as misoprostol (Cytotec) have not been shown to be effective in the prophylaxis of stress-related erosive syndrome. Synthetic prostaglandin analogues exert a cytoprotective effect at low doses and have been demonstrated to protect the gastric mucosa from a variety of agents. Given the relatively high cost and major side effects associated with their use, it is unlikely that any large scale randomized clinical trial will be performed to investigate the role of prostaglandin analogues in stress-related erosive syndrome hemorrhage; therefore, the use of these agents in the prophylaxis of SERS cannotbe recommended.
Adverse Effects and Precautions
Constipation is the most frequently reported adverse effect of sucralfate although diarrhoea, nausea, vomiting, flatulence, or gastric discomfort may also occur. Other adverse effects include dry mouth, dizziness, drowsiness, headache, vertigo, back pain, and skin rashes. Hypersensitivity reactions such as pruritus, oedema, urticaria, respiratory difficulty, rhinitis, laryngospasm, and facial swelling have been reported. Great caution is needed in patients with renal impairment (below) as absorption and accumulation of aluminium may cause adverse effects.
Bezoar formation
As of March 1999, the UK CSM was aware of 7 reports worldwide of bezoar formation associated with sucralfate use in intensive care patients. It advised caution in the use of sucralfate in seriously ill patients because of the risks of bezoar formation and intestinal obstruction. Patients with delayed gastric emptying or receiving concomitant enteral feeds may be at increased risk. A report by the French Pharmacovigilance System at about the same time made similar recommendations but also contra-indicated the use of sucralfate in premature and immature neonates.
Renal impairment
Sucralfate under acid conditions can release aluminium ions that may be absorbed systemically Significant increases in the urinary excretion of aluminium have been seen in healthy subjects given sucralfate 4g daily reflecting gastrointestinal absorption of aluminium aluminium concentrations in serum and urine were significantly higher in patients with chronic renal impairment than in subj ects with normal renal function, and similar serum increases have been seen in children with acute renal failure.
Aluminium toxicity in patients with normal renal function receiving sucralfate would not be expected, but seizures, muscle weakness, bone pain, and severe aluminium encephalopathy have been reported in patients with end-stage renal disease requiring dialysis. Sucralfate should be used with caution in patients with renal impairment, especially if other aluminium-containing agents are also taken, and such patients should be monitored for signs of aluminium toxicity.
Interactions
Sucralfate may interfere with the absorption of other drugs and it has been suggested that there should be an interval of 2 hours between giving sucralfate and other non-antacid medication. Some of the drugs reported to be affected by sucralfate include cimetidine, ranitidine, digoxin, fluoroquinolone antibacterials, ketoconazole, levothyroxine, phenytoin, tetracycline, quinidine, theophylline, and possibly warfarin. The recommended interval between sucralfate and antacids is 30 minutes. An interval of 1 hour should elapse between giving sucralfate and enteral feeding.
Pharmacokinetics
Sucralfate is only slightly absorbed from the gastrointestinal tract after oral doses. However, there can be some release of aluminium ions and of sucrose sulfate small quantities of sucrose sulfate may then be absorbed and excreted, primarily in the urine some absorption of aluminium may also occur (see Renal Impairment, above).
Uses and Administration
Sucralfate is a cytoprotective drug that, under acid gastrointestinal conditions, forms an adherent complex with proteins which coats the gastric mucosa and is reported to have a special affinity for ulcer sites. It also inhibits the action of pepsin and adsorbs bile salts. Sucralfate has been used in the treatment of peptic ulcer disease and chronic gastritis. It is given orally and should be taken on an empty stomach before meals and at bedtime. The usual dose is 1 g four times daily or 2 g twice daily for 4 to 8 weeks if necessary the dose may be increased to a maximum of 8 g daily. If longer-term therapy is required sucralfate may be given for up to 12 weeks. Where appropriate a maintenance dose of 1 g twice daily may be given to prevent the recurrence of duodenal ulcers. For prophylaxis of gastrointestinal haemorrhage from stress ulceration the usual dose of sucralfate is 1 g six times daily a dose of 8 g daily should not be exceeded. For children’s doses see below.
Administration in children
Although sucralfate is not licensed in the UK for use in children under 15 years, the BNFC recommends the following oral doses for the treatment of peptic ulcer disease, or the prophylaxis of stress ulceration in children in intensive care (but see also under Bezoar Formation, above):
- 1 month to 2 years: 250 mg four to six times daily
- 2 to 12 years: 500 mg four to six times daily
- 12 to 18 years: 1 g four to six times daily
The oral suspension blocks fine-bore feeding tubes and tablets should be crushed and dispersed in water instead.
Gastrointestinal bleeding
Sucralfate is an effective drug for the prophylaxis and management of stress-induced gastrointestinal bleeding in severely ill patients but whether it should be chosen over an H2-antagonist has been subject to debate. One study suggested it might reduce the risk of late-onset pneumonia compared with ranitidine. Another study found ranitidine to be more effective than sucralfate in reducing the risk of gastrointestinal bleeding while there was a trend towards a lower rate of pneumonia among patients receiving sucralfate, the difference was not significant.
However, meta-analyses found an increased risk of pneumonia with ranitidine compared with sucralfate, but no difference in the rate of pneumonia with sucralfate and placebo insufficient data were available to conduct a meta-analysis of sucralfate’s efficacy in terms of rates of bleeding, and a re-assessment of recommendations for the prophylaxis of stress ulcers was called for. Later guidelines concluded that the use of sucralfate did not influence the incidence of ventilator-associated pneumonia compared with placebo. For further discussion of stress ulceration and bleeding, including the use of sucralfate, see under Peptic Ulcer Disease. There is also some evidence from a study that sucralfate reduces gastrointestinal bleeding associated with NSAID use, although it does not prevent drug-induced gastric erosion.
In a study to assess whether oral prophylactic sucralfate could ameliorate the symptoms of acute radiation proctitis, sucralfate was found to increase the incidence of rectal bleeding compared with placebo the cause of this increased bleeding was unclear.
Gastro-oesophageal reflux disease
Although sucralfate has been tried for gastro-oesophageal reflux disease the results of studies have been inconsistent. However, if lifestyle or dietary measures prove insufficient for the management of heartburn in pregnancy, sucralfate may be considered for first-line therapy.
Mouth ulceration
Sucralfate has been investigated as a mouth rinse in the treatment and prophylaxis of stomatitis induced by cancer chemotherapy although evidence of benefit for any drug is ambiguous (see Mucositis). One study in 40 patients found a significant reduction in symptoms among 23 eval-uable patients given sucralfate prophylactically. Seven patients withdrew due to aggravation of chemotherapy-induced nausea. It was suggested that to overcome this problem, the suspension should have a neutral taste, should not be swallowed after rinsing, and that rinsing should not be started until nausea had stopped.
However, another study involving 80 patients treated with fluorouracil for colorectal cancer found no significant difference in self-reported mucositis symptoms between patients given sucralfate suspension and those given placebo. Sucralfate has also been reported to be of benefit in patients with recurrent aphthous stomatitis (mouth ulceration). A study involving 21 such patients over 2 years found that topical application of sucralfate suspension 4 times daily was superior to treatment with an antacid (aluminium hydroxide with magnesium hydroxide) or placebo.
In patients with Behcefs syndrome, topical sucralfate suspension significantly decreased the frequency, healing time, and pain of oral ulceration, as well as the healing time and pain of genital ulceration, when compared with placebo.
Skin ulceration
Sucralfate has reportedly been applied topically with some success to treat bleeding skin ulcers associated with malignancy, and to promote the healing of venous stasis ulcers. It has been suggested that sucralfate promotes angiogenesis by binding to, and preventing degradation of, basic fibroblast growth factor (bFGF). Topical sucralfate 7% cream was also reported to decrease pain and speed healing of the wound after open surgical removal of haemorrhoids.
Preparations
The United States Pharmacopeia 31, 2008: Sucralfate Tablet.
Proprietary Preparations
Argentina: Antepsin Netunal Sucralmax
Australia:: Carafate Ulcyte
Austria: Citogel Sucralan Sucralbene Sucralstad Sucramed Ulceral Ulcogant
Belgium: Ulcogant
Brazil: Sucrafilm
Canada: Novo-Sucralate Sulcrate
Chile: Gastrocol Mulcatel Sulcran
Czech Republic: Sucralan Ulcogant Venter
Denmark: Antepsin Hexagastron
Finland: Alsucral Antepsin Fn Keal Ulcar
Germany: Sucrabest Sucraphil Ulcogant
Greece: Peptonorm Sucrate
Hong Kong: Sucari Ulsanic
Hungary: Alusulin Ulcogant Venter
India: Alfate Sucrase Ulcekon
Indonesia: Inpepsa Musin Neciblok Ulcumaag Ulsafate Ulsicral Ulsidex
Ireland: Antepsin
Israel: Ulsanic
Italy: Antepsin Citogel Crafilm Escudo Gastrogel Ipagastril-b Sucrager Sucral Sucralfin Sucramal Sucrate Sucroril Sugar Sugast Suril Ulcrast Zenodian
Japan: Ulcerlmin
Malaysia: Alsucral Ulcertec
Mexico: Apo-Lato Unival
The Netherlands: Ulcogant
Norway: Antepsin
New Zealand: Carafate
Philippines: Iselpin
Poland: Ulgastran Venter
Portugal: Calfate Cinebil Sucralum Ulcermate Ulcermin Ulcimer
Russia: Venter
South Africa: Ulcetab Ulsanic
Singapore: Alsucral Ulcertec
Spain: Gastral Urbal
Sweden: Andapsin
Switzerland: Ulcogant
Thailand: Sucrafen Sucral Sucrate Ulcefate Ulcrafate Ulsanic
Turkey: Antepsin
United Arab Emirates: Sucralose
UK: Antepsin
USA: Carafate
Venezuela: Dip Exinol Ulciram Ulcon
Multi-ingredient
Chile: Cicalfate
France: Cicalfate
Greece: Profenil
Used as an adjunct in: Italy: Ketodol
Jennifer is a clinical pharmacologist. She helps doctors of all medical specialties choose medications. Jennifer consults about drug dosage, interactions, and side effects.