Sucralfate 💊

🩺 Sucralfate is a mucosal protectant used in peptic ulcer disease and stress ulcer prophylaxis. It acts locally, coating ulcerated mucosa and forming a physical barrier against acid, pepsin, and bile salts. 💡 Best given on an empty stomach before meals and at bedtime.

🧠 About

• Composed of aluminium hydroxide complexed with sulfated sucrose.
• Forms a viscous, sticky gel that adheres to ulcer bases and epithelial cells in acidic conditions (pH < 4).
• Provides a local “bandage” effect rather than systemic acid suppression.
• Useful for gastric and duodenal ulcers, chronic gastritis, and stress ulcer prevention in critically ill patients.

⚙️ Mode of Action

• In acidic environments, sucralfate polymerises to form a viscous, negatively charged complex that binds to positively charged proteins at the ulcer base.
• This barrier protects mucosa from pepsin, acid, and bile reflux.
• Also stimulates prostaglandin synthesis and bicarbonate secretion, enhancing mucosal defence and repair.
• No significant systemic absorption — most of its action is local.

🎯 Indications

• Benign gastric or duodenal ulceration (acute or chronic).
• Chronic gastritis or erosive gastritis.
• Prophylaxis of stress-related mucosal damage (e.g. in ICU or ventilated patients).
• Alternative to proton pump inhibitors when acid suppression is contraindicated (e.g. risk of infection, C. difficile).

💊 Dose

• Benign gastric ulceration: 1 g QDS or 2 g BD before meals and at bedtime for 6–12 weeks.
• Duodenal ulceration: 1 g QDS or 2 g BD for 6–12 weeks.
• Chronic gastritis: 1 g QDS or 2 g BD for up to 12 weeks.
• Stress ulcer prophylaxis: 1 g every 4 hours (max 8 g/day) PO or via nasogastric tube.

⚠️ Cautions

• Do not administer simultaneously with enteral feeds — risk of bezoar formation and feed occlusion.
• Space at least 2 hours apart from other oral medications (it can reduce absorption).
• Use with caution in renal impairment due to aluminium accumulation and potential toxicity.
• Monitor in elderly or immobile patients — constipation risk.

🚫 Contraindications

• Known hypersensitivity to sucralfate or its components.
• Severe renal failure (risk of aluminium accumulation).
• Previous bezoar formation or GI obstruction.

💊 Adverse Effects

• Common: constipation (from aluminium content).
• Occasional: dry mouth, nausea, back pain.
• Rare: bezoar formation (especially in enterally fed or debilitated patients).
• Very rare: hypophosphataemia, aluminium toxicity in renal failure.

🤰 Pregnancy and Breastfeeding

• Generally considered safe in pregnancy — minimal systemic absorption.
• Compatible with breastfeeding (acts locally in the GI tract).

🩺 Clinical Pearls

• Take on an empty stomach (1 hour before or 2 hours after food) for best mucosal adherence.
• Separate from other oral drugs by 2 hours — sucralfate can bind and impair their absorption (e.g. digoxin, ciprofloxacin, warfarin, phenytoin).
• Prefer liquid formulation if patient has difficulty swallowing or for nasogastric administration.
• Useful in ICU stress ulcer prophylaxis when acid suppression is contraindicated (e.g. pneumonia risk).

💡 Teaching Tip

• Contrast with PPIs and H₂ blockers — sucralfate does not reduce acid secretion but rather protects mucosa.
• Mnemonic: “SUCralfate SUCks onto ulcers” — sticks to the ulcer base to protect healing tissue.
• Bezoars form when sucralfate binds to enteral feed proteins → emphasise spacing doses.

📚 References

• BNF: Sucralfate
• NICE CKS: Dyspepsia and Peptic Ulcer (2024)
• Konturek SJ et al., J Physiol Pharmacol 2011;62(6):555–564 — Gastric protection mechanisms.