A Textbook of Clinical Pharmacology and Therapeutics

SUCRALFATE

Use

Sucralfateis used in the management of benign gastric and duo-
denal ulceration and chronic gastritis. Its action is entirely local,
with minimal if any systemic absorption. It is a basic aluminium
salt of sucrose octasulphate which, in the presence of acid,
becomes a sticky adherent paste that retains antacid efficacy. This
material coats the floor of ulcer craters, exerting its acid-neutral-
izing properties locally, unlike conventional antacid gels which
form a diffusely distributed antacid dispersion. In addition it
binds to pepsin and bile salts and prevents their contact with the
ulcer base. Sucralfatecompares favourably with cimetidinefor
healing both gastric and duodenal ulcers, and is equally effective
in symptom relief. The dose is 1 g (one tablet) four times daily for
four to six weeks. Antacids may be given concurrently.

Adverse effects

Sucralfateis well tolerated but, because it contains aluminium,
constipation can occur and in severe renal failure accumulation
is a potential hazard.

2.avoiding:

• large meals;


• alcohol and/or food before bed;


• smoking, which lowers the lower oesophageal
  sphincter pressure, and coffee;


• aspirinand NSAIDs;


• constricting clothing around the abdomen;
  3.weight reduction;
  4.bending from the knees and not the spine;
  5.regular exercise.

DRUG THERAPY

Drugs that may be useful include the following:

1. metoclopramide, which increases oesophageal motility as
   well as being anti-emetic. It may also improve gastro-
   oesophageal sphincter function and accelerate gastric
   emptying;
   2.a mixture of alginate and antacids is symptomatically
   useful – the alginate forms a viscous layer floating on the
   gastric contents;
   3.symptomatic relief may be obtained with antacids, but
   there is a risk of chronic aspiration of poorly soluble
   particles of magnesium or aluminium salts if these are
   taken at night;
   4.H 2 -antagonists;
   5.proton-pump inhibitors are the most effective
   agents currently available for reflux oesophagitis
   and are the drugs of choice for erosive reflux
   oesophagitis.

252 ALIMENTARY SYSTEM ANDLIVER

Case history

A 75-year-old retired greengrocer who presented to the

Accident and Emergency Department with shortness of

breath and a history of melaena is found on endoscopy to

have a bleeding gastric erosion. His drug therapy leading up

to his admission consisted of digoxin, warfarin and piroxi-

cam for a painful hip, and over-the-counter cimetidine self-

initiated by the patient for recent onset indigestion.

Question

How may this patient’s drug therapy have precipitated or

aggravated his bleeding gastric erosion?

Answer

NSAIDs inhibit the biosynthesis of prostaglandin E 2 , as well

as causing direct damage to the gastric mucosa. Warfarin is

an anticoagulant and will increase bleeding. Cimetidine

inhibits CYP450 enzymes and therefore inhibits the metab-

olism of warfarin, resulting in higher blood concentrations

and an increased anticoagulant effect.

Case history

A 25-year-old male estate agent complains of intermittent

heartburn, belching and sub-xiphisternal pain which has

been present on most nights for two weeks. It was particu-

larly severe the previous Saturday night after he had con-

sumed a large curry and several pints of beer. The symptoms

were not improved by sleeping on two extra pillows or by

taking ibuprofen. He smokes ten cigarettes daily. Examina-

tion revealed him to be overweight, but was otherwise

unremarkable.

Question

Outline your management of this patient.

Answer

Life-style advice – stop smoking, lose weight and exercise,

adopt a low-fat diet, avoid tight clothing, avoid large meals

or eating within three hours of going to bed. Raise the head

of the bed (do not add pillows). Avoid NSAIDs and excessive

alcohol.

Prescribe alginate/antacids.

If there is an inadequate response or early relapse, prescribe

an H 2 -blocker or proton-pump inhibitor for six weeks. If

symptoms have still not completely resolved, refer the

patient for endoscopy.

OESOPHAGEAL DISORDERS

REFLUX OESOPHAGITIS

Reflux oesophagitis is a common problem. It causes heartburn
and acid regurgitation and predisposes to stricture formation.

NON-DRUG MEASURES

Non-drug measures which may be useful include the following:

1. sleeping with the head of the bed raised. Most damage to
   the oesophagus occurs at night when swallowing is much
   reduced and acid can remain in contact with the mucosa
   for long periods;