Short-term treatment of duodenal ulcer. A comparison of sucralfate and cimetidine

What are the current possibilities in treating peptic ulcer disease?

There are two major principles of ulcer therapy. Today, the most widely accepted drugs are those which substantially reduce aggressive factors (i.c. acid and pepsin), namely histamine H2-receptor antagonists, antimuscarinics and antacids. Less frequently applied are mucoprotective agents like colloidal bismuth compounds and sucralfate. Prostaglandins both reduce acid secretion substantially and are believed to enhance mucosal resistance. Their anti-ulcer efficacy, however, is solely explicable by their antisecretory activity. Although mucosa-strengthening agents and H2-receptor blockers have nearly identical healing rates, mucosa-strengthening agents have inconvenient dosage regimens (four times or twice daily) and are probably less effective in relieving pain. The same holds true for antacids. Prostaglandins, antimuscarinics and antacids have dose related side effects. In contrast, H2-receptor blockers are characterized by a clear mechanism of action, convenient dosage regimens, good tolerance and a low incidence of side-effects. H2-receptor antagonists are the most effective anti-ulcer drugs presently available.

Epidemiology in peptic ulcer disease. Current status and future aspects

Peptic ulcer incidence is declining. A decreased prevalence of smokers together with other factors have contributed to this change. The widespread use of non-steroidal anti-inflammatory drugs (NSAID) has increased the incidence of ulcer in the older population and serious complications, such as perforation and bleeding, have been observed especially in older women. Helicobacter pylori infection is virtually always present in duodenal and gastric ulcer and active chronic gastritis, but not prepyloric ulcer. The fact that this organism is not eradicated with the use of most drugs for peptic ulcer may explain the high rate of recurrence in ulcer disease since relapse rates are reported to be considerably lower when H. pylori is eradicated. In a substantial number of patients peptic ulcers are silent. These fall into two categories: the regular ulcer patient with relapses that heal spontaneously and rarely cause problems, and older patients without prior ulcer disease receiving NSAID treatment, presenting with a life-threatening complication as the first indication of ulcer disease. Despite all the new knowledge of peptic ulcer disease presented, the questions still outnumber the answers; it is therefore suggested that future research focus on the role of NSAIDs and H. pylori.

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.

Cimetidine and adverse reactions: a meta-analysis of randomized clinical trials of short-term therapy

PURPOSE

We pooled data from randomized, double-blind, placebo-controlled trials to determine the frequency of adverse reactions among patients treated with cimetidine for acute acid-peptic disorders.

METHODS

Meta-analysis was used to analyze data obtained from a search of English language reports of trials of cimetidine in the ambulatory treatment of acute acid-peptic disorders that were published between January 1982 and April 1987.

RESULTS

Of 161 trials of cimetidine that we identified, 84 provided complete reporting of data on adverse reactions and, of these, 24 employed a randomized, double-blind, placebo-controlled design. Across these 24 trials, the overall rate of reported adverse reactions among 622 patients randomly assigned to receive cimetidine was 10.9%; the corresponding rate among 516 patients randomly assigned to receive placebo was 10.1%. This difference was not statistically significant (p greater than 0.10), nor were any significant differences noted in the frequencies of reported central nervous system or gastrointestinal adverse reactions (p greater than 0.10). Rates of adverse reactions also did not differ by dosage or trial duration. The overall rate of adverse reactions reported in the 60 trials that did not utilize a randomized, double-blind, placebo-controlled design was similar to the rate reported in those that did.

CONCLUSIONS

Our findings suggest that the frequency of adverse reactions among patients receiving cimetidine for acute acid-peptic disorders is not significantly different from that of patients receiving placebo.

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

Sucralfate suspension 1 g/10 ml four times per day was found to be significantly better than placebo for the healing of active duodenal ulcer. An eight-week, double-blind, randomized, placebo-controlled, parallel-group multicenter study was conducted. A total of 292 patients were evaluated. Ulcer healing was evaluated by endoscopy and symptom assessment occurred at baseline and at two, four, and eight weeks, or upon symptom worsening as determined by the investigator. Healing was defined as complete re-epithelialization of the crater, without residual erosion. Patients completed eight weeks of treatment regardless of whether or not they were healed at two or four weeks. Treatment groups were comparable with regard to age, sex, ulcer history, cigarette smoking, alcohol and caffeine consumption, ulcer size, and ulcer symptoms. Analysis of procedurally correct cases demonstrated that sucralfate suspension was significantly more effective in healing duodenal ulcers than placebo at two, four, and eight weeks. Ulcer-healing rates efficacy analysis are as follows. At two weeks, the healing rate of sucralfate suspension was 22 of 125 patients (18 percent) and the healing rate of placebo suspension was eight of 130 patients (6 percent; p = 0.006). At four weeks, 58 of 114 patients (51 percent) for sucralfate and 38 of 112 patients (34 percent) for placebo (p = 0.011) were healed. At eight weeks, 80 of 105 (76 percent) for sucralfate and 53 of 100 (53 percent) for placebo (p = 0.001) were healed. Sucralfate-treated patients experienced significantly greater reductions in both daytime and nighttime pain scores at two weeks. A significant difference between treatment groups was also found for daytime symptoms at four weeks. At four and eight weeks, patients who smoked cigarettes had significantly lower healing rates than those who did not, regardless of treatment group. Sucralfate suspension was found to be effective for the treatment of active duodenal ulcer.

Twice-daily sucralfate dosing to heal acute duodenal ulcer. Multicenter Study Group

Twice-daily dosing with sucralfate was evaluated by two multicenter trials, trial 1 (eight weeks) and trial 2 (four weeks). Both trials demonstrated significantly better ulcer healing at study completion for the 2-g twice daily (B.I.D.) regimen compared with placebo. Both trials were double-blind, randomized, and placebo-controlled, with parallel groups. Patients received two doses daily consisting of sucralfate 2 g B.I.D., placebo/sucralfate 2 g at bedtime (H.S.), or placebo/placebo. Ulcer healing was assessed by scheduled endoscopy and symptom assessment. Healing was defined as complete absence of erosion or ulceration. Trial 1 evaluations were conducted at four and eight weeks, trial 2 evaluations at two and four weeks. Interim examinations were performed at investigator discretion. Treatment groups were comparable with regard to number of patients, age, sex, smoking status, ulcer size, and presence/absence of baseline symptoms. Sucralfate 2 g B.I.D. was significantly better than H.S. or placebo dosing at the completion of each trial. H.S. dosing was better than placebo only at the four-week analysis of trial 1. At Week 4 of trial 1, 14 of 54 patients (26 percent) were healed with the B.I.D. sucralfate regimen, whereas at Week 8, 41 of 54 (76 percent) were healed (p less than 0.001). For the placebo/sucralfate H.S. group, 17 of 57 patients (30 percent) were healed at Week 4 (p less than 0.05), and 32 of 56 patients (57 percent) were healed at Week 8. For the placebo group, six of 52 (12 percent) and 20 of 51 patients (39 percent) were healed at Weeks 4 and 8, respectively. In trial 2, the B.I.D. group had a 21 percent healing rate at Week 2 (13 of 61 patients) and 62 percent were healed at Week 4 (38 of 61 patients; p less than 0.05). The H.S. group had an 8 percent healing rate (five of 66 patients) at Week 2 and 50 percent (33 of 66 patients) at Week 4. For the placebo group, 10 of 62 patients (16 percent) and 26 of 62 patients (42 percent) were healed at Weeks 2 and 4, respectively. Trial 1 demonstrated significant symptom improvement for active treatment groups at both four and eight weeks, whereas no differences were found in trial 2. Sucralfate 2 g B.I.D. was found to be safe and effective for the treatment of acute duodenal ulcer.

Comparative study of sucralfate versus cimetidine in the treatment of acute gastroduodenal ulcer. Randomized trial with 667 patients

Six-hundred sixty-seven patients with endoscopically proven peptic ulcer were included in a randomized, multicenter trial to assess the comparative efficacy of sucralfate and cimetidine. One hundred eighty-seven patients with gastric ulcer and 480 patients with duodenal ulcer completed the study. Ulcer healing was evaluated endoscopically at six weeks for duodenal ulcer and at eight weeks for gastric ulcer. Patients with unhealed ulcer at this time were assigned to the other therapy for a second period of six or eight weeks of treatment (crossover). In patients with duodenal gastric ulcer, pain relief and healing were not significantly different in the two groups. Eighty-eight percent of duodenal ulcers and 73 percent of gastric ulcers healed with six weeks of sucralfate treatment. Reported side effects and symptoms, pooled together for duodenal and gastric ulcer, were more significant in the sucralfate group (7.5 percent) than in the cimetidine group (3.7 percent). Constipation was the most frequent symptom recorded. In conclusion, sucralfate and cimetidine are both excellent healing agents for short-term treatment of duodenal and gastric ulcer. Both give rapid relief of symptoms without severe side effects.

Relapse rate of healed duodenal, prepyloric, and gastric ulcers treated either with sucralfate or cimetidine

A multicenter double-blind study was designed to compare the relapse rates of peptic ulcers after initial healing with a cytoprotective agent and a histamine (H2)-receptor antagonist. Patients with endoscopically verified prepyloric or duodenal ulcers were treated with cimetidine 400 mg twice daily or sucralfate 1 g four times daily for a maximum of eight weeks; gastric ulcers were treated for up to 12 weeks. Patients with healed ulcers were followed up to 12 months, during which time anti-ulcer medication was not permitted. Control endoscopy was performed two to four and nine to 11 months after healing and at the time of symptomatic relapse. A total of 258 patients were followed for 12 months; of these, 143 had been previously treated with cimetidine and 115 had been treated with sucralfate. The relapse rates and the median time to relapse did not differ between the two groups. After 12 months, 71 percent of the previously cimetidine-treated patients and 68 percent of the sucralfate-treated patients had experienced a relapse. Smoking significantly increased the relapse rate and shortened the time to relapse in the total study population and among cimetidine-treated patients; it had no such effect in the sucralfate-treated group.

Recurrent ulcer after treatment with cimetidine or sucralfate

The recurrence of peptic ulcer disease after successful treatment with 400 mg cimetidine twice daily or 1 g sucralfate four times daily was investigated in a double-blind, 1-year follow-up study. Endoscopy was performed if ulcer symptoms recurred and 2-4 and 9-11 months after endoscopically confirmed healing of the initial ulcer. No anti-ulcer medication was permitted during the follow-up period. The recurrence rates were 71% in the cimetidine group (n = 143) and 68% in the sucralfate group (n = 115) (p greater than 0.3). The rate of asymptomatic ulcer relapse was 26% in the cimetidine and 23% in the sucralfate group (p greater than 0.4). The time to relapse did not differ between the treatment groups (p greater than 0.3). In the cimetidine group smokers had a higher 12-month recurrence rate than non-smokers, 83% compared with 58% (p less than 0.01). The corresponding figures in the sucralfate group were 76% and 57% (p = 0.057). The median time to recurrence in the cimetidine-treated group was 17 weeks among smokers, compared to 43 weeks among non-smokers (p less than 0.001). In the sucralfate-treated group the median time to recurrence was 23 weeks among smokers and 32 weeks among non-smokers (p greater than 0.3). Pre-study use of non-steroidal anti-inflammatory drugs and the time to healing of the initial ulcer did not influence the relapse rates in either of the treatment groups.

Urinary excretion of aluminium after ingestion of sucralfate and an aluminium-containing antacid in man

Eleven subjects with normal renal function were given, on 2 separate days, at least 1 week apart, four tablets of sucralfate or an aluminium (Al)-containing antacid. The total Al load was approximately 976 mg with the antacid and approximately 828 mg with sucralfate. The daily urinary excretion of Al was measured the day before and during 3 days after drug administration. Al excretion increased significantly after both drugs. There was no significant difference between the two products. The median absorption calculated as percentage of Al dose was 0.005% (range, 0.001-0.017%) for sucralfate and 0.006% (range, 0.002-0.060%) for the antacid. Thus, measurable quantities of aluminium is absorbed after administration of sucralfate, and the drug should, like Al-containing antacids, be given with caution to patients with renal failure.

Medical care of the surgical patient with gastrointestinal disease

Common perioperative gastrointestinal disorders of surgical patients are presented. Recommendations for appropriate medical evaluation and management are described.

Clinical pharmacology of the gastrointestinal tract

This article discusses the various drugs that affect the equine gastrointestinal tract. Drugs that alter intestinal motility, that protect the gastrointestinal tract, and that alter secretions, as well as analgesics, appetite stimulants, and orally administered antimicrobial agents are reviewed.

Short-term treatment of prepyloric ulcer. Comparison of sucralfate and cimetidine

A double-blind, randomized, multicenter study was performed to compare the effect of sucralfate (1 g qid) and cimetidine (400 mg bid) in the treatment of prepyloric ulcer. Altogether 142 patients (68 in the sucralfate and 74 in the cimetidine group) with endoscopically confirmed ulcer within 2 cm of the pylorus completed the study. Endoscopic follow up was performed after four weeks and, if the ulcer was not healed, after eight weeks of treatment. After four weeks, 65% of the ulcers in the sucralfate group were healed, compared to 70% in the cimetidine group. There was no significant difference between sucralfate and cimetidine at either time point. The 95% confidence interval for the difference in ulcer healing with sucralfate or cimetidine ranged from +4 to -19% at eight weeks. Said another way, with an observed difference of 7% (83% vs 90%), the 95% confidence limit ranged from 4% in favor of sucralfate to 19% in favor of cimetidine. Symptomatic relief, antacid intake, and side effects did not differ significantly between the two groups. The healing rate of prepyloric ulcer in this study is similar to that reported for duodenal ulcer after four and eight weeks when treated with sucralfate or cimetidine. Sucralfate is safe and as effective as cimetidine in the short-term treatment of prepyloric ulcer.

Swedish multicenter study on prepyloric and gastric ulcer

A double-blind, randomized, multicenter study was performed to compare the effects of sucralfate and cimetidine for the short-term treatment of gastric and prepyloric ulcers. Ulcer healing was evaluated endoscopically at 4-week intervals up to 8 weeks in the PPU study and up to 12 weeks in the GU study. A total of 142 PPU and 134 GU patients completed the study. The overall healing rates after 8 weeks in the PPU study were 83% for the sucralfate group and 90% for the cimetidine group (NS), while the cumulative healing rates after 12 weeks in the GU study were 98% for the sucralfate group and 94% for the cimetidine group (NS). The confidence interval means that the 95% confidence limit ranges from 11% in favour of sucralfate to 2% in favour of cimetidine in the GU study and corresponding figures of 4% 19% in the PPU study. There were significantly more patients in the cimetidine group taking antacid tablets after 3 weeks in the GU study. Symptomatic relief did not differ significantly. Reported side effects and symptoms, pooled together with our duodenal ulcer study, were mostly non-specific and in some part related to the ulcer disease. In conclusion, sucralfate and cimetidine are both excellent healing agents for the short-term treatment of PPU and GU. Both give rapid and good symptomatic relief with no side effects of any importance.