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Other Ulcer Healing Drugs

Because of the effectiveness and safety of proton pump inhibitors and H2 receptor antagonists, the other ulcer healing drugs are now seldom indicated. They are not recommended for non-ulcer dyspepsia because of unproven benefit and potential adverse effects.

Tripotassium dicitratobismuthate
  • Promotes the healing of peptic ulcers by forming a bismuth/glycoprotein precipitate which forms a protective cover over the base of the ulcer.
  • The effectiveness in treating peptic ulcers is similar to cimetidine and with a lower relapse rate. However its use is limited by side-effects and it should not be used for long term therapy.
  • Indications:1
    • Gastric and duodenal ulcers
    • As part of a Helicobacter pylori eradication regime in those who have not responded to first-line regimens2
  • Interactions:
    • Tetracyclines: the absorption of tetracyclines is reduced
  • Contra-indications:
  • Side-effects:
    • May cause a dark tongue and black stools
    • Nausea and vomiting
    • There may be absorption of small quantities of bismuth but encephalopathy (which may occur with high-dose bismuth preparations) has not been reported
Sucralfate
  • Probably acts by protecting the mucosa from acid-pepsin attack in gastric and duodenal ulcers. It also stimulates production of mucus and prostaglandins.
  • Sucralfate is a complex of aluminium hydroxide and sulphated sucrose but does not have any significant antacid properties.
  • Sucralfate is as effective in the treatment of peptic ulcers as H2 antagonists.3
  • Indications:4
    • Benign gastric and duodenal ulceration
    • Chronic gastritis
    • Prophylaxis of stress ulceration
  • Cautions:
    • Renal impairment (avoid if severe)
    • Pregnancy and breast-feeding
    • Not recommended in children
    • Administration of sucralfate and enteral feeds should be separated by 1 hour
    • Bezoar formation: following reports of bezoar formation associated with sucralfate, the Committee on Safety of Medicines has advised caution in seriously ill patients, especially those receiving concomitant enteral feeds or those with predisposing conditions such as delayed gastric emptying.5 A bezoar is a ball of swallowed foreign material (e.g. hair) that collects in the stomach and fails to pass through the intestines.
  • Interactions:
    • Sucralfate reduces the absorption of certain antibiotics (quinolones and tetracyclines), warfarin, phenytoin, antifungals, sulpiride and thyroxine. It may also reduce the absorption of digoxin.
  • Side-effects:
Prostaglandin analogues

Misoprostol is a synthetic prostaglandin E1 analogue. It inhibits gastric acid secretion and stimulates the production of mucus and bicarbonate.

  • It is effective in preventing NSAID-associated ulcers.
  • Misoprostol is as effective as H2 antagonists in healing duodenal ulcers but is less effective in the treatment of gastric ulcers and gastro-oesophageal reflux disease.
  • Although effective, its use is mainly restricted because of potential side effects.
  • Misoprostol is also used to induce abortion or labour.
  • Indications:6
    • Gastric and duodenal ulceration; NSAID-associated ulceration
    • Prophylaxis of NSAID-induced gastric and duodenal ulcer.7 Misoprostol is more effective than H2 receptor antagonists for preventing NSAID-associated ulceration but is associated with a greater cost and GI side-effects.8 Combination preparations with misoprostol are available for prophylaxis against NSAID-induced gastro-intestinal ulceration:
  • Contra-indications:
    • Pregnancy or planning pregnancy, breast-feeding. Use in women of childbearing age is restricted to NSAID induced ulceration (or risk of), and then only with effective contraception.
    • Not recommended in children.
  • Side-effects:
    • Diarrhoea (may occasionally be severe and require withdrawal).
    • May also cause abdominal pain, dyspepsia, flatulence, nausea and vomiting, abnormal vaginal bleeding, rashes and dizziness.

Document references
  1. Summary of Product Characteristics De-Noltab®; (Tri-potassium di-citrato bismuthate) Astellas Pharma Ltd Updated Nov 2005 electronic Medicines Compendium
  2. Kearney DJ; Retreatment of Helicobacter pylori infection after initial treatment failure.; Am J Gastroenterol. 2001 May;96(5):1335-9. [abstract]
  3. Candelli M, Carloni E, Armuzzi A, et al; Role of sucralfate in gastrointestinal diseases.; Panminerva Med. 2000 Mar;42(1):55-9. [abstract]
  4. Summary of Product Characteristics Antepsin®; Tablets 1g (sucralfate), Chugai Pharma UK Limited (updated 15 Nov 2006) electronic Medicines Compendium.
  5. CSM; Bezoar formation with sucralfate (Antepsin); Current Problems in Pharmacovigilance: Volume 25 March 1999
  6. Summary of Product Characteristics Cytotec®; Tablets. Pharmacia Limited, updated July 2004, electronic Medicines Compendium
  7. Rostom A, Dube C, Wells G, et al; Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database Syst Rev. 2002;(4):CD002296. [abstract]
  8. Brown TJ, Hooper L, Elliott RA, et al; A comparison of the cost-effectiveness of five strategies for the prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal toxicity: a systematic review with economic modelling. Health Technol Assess. 2006 Oct;10(38):iii-iv, xi-xiii, 1-183. [abstract]
  9. Summary of Product Characteristics - Arthrotec 75®; (diclofenac sodium and misoprostol) Pharmacia Limited, updated 9 Nov 2005; electronic Medicines Compendium.
AcknowledgementsEMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
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Document Version: 2
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Last Updated: 16 Oct 2007
Review Date: 15 Oct 2008




















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