DESCRIPTION

Sucralfate is a sucrose-aluminum preparation that is used for a variety of peptic pathologic conditions; toxicity is rare.

FORMS AND USES

• Sucralfate (Carafate) is used for therapy of acute duodenal ulcers and for maintenance therapy after healing.
• It is also used in a variety of gastrointestinal peptic conditions, including treatment of gastroesophageal reflux disease.
  • Adult dosage for ulcer therapy is 1 g by mouth four times a day.
  • Pediatric dosage has not been established.

TOXIC DOSE

No toxic dose has been established.

PATHOPHYSIOLOGY

Sucralfate is a poorly absorbed sucrose-aluminum preparation that binds to the gastrointestinal mucosa, thereby offering protection from local acid injury.

EPIDEMIOLOGY

Poisoning is uncommon.

CAUSES

Child neglect or abuse should be considered if the patient is less than 1 year of age, suicide attempt if the patient is over 6 years of age.

DRUG AND DISEASE INTERACTIONS

Patients on dialysis who are treated with sucralfate may develop aluminum toxicity.

PREGNANCY AND LACTATION

US FDA Pregnancy Category B. Animal studies indicate no fetal risk and there are no controlled human studies, or animal studies show an adverse fetal effect but well-controlled studies in women do not.

Section Outline:

• DESCRIPTION
• FORMS AND USES
• TOXIC DOSE
• PATHOPHYSIOLOGY
• EPIDEMIOLOGY
• CAUSES
• DRUG AND DISEASE INTERACTIONS
• PREGNANCY AND LACTATION

DIFFERENTIAL DIAGNOSIS

Aluminum toxicity may appear similar to lithium toxicity, alcohol intoxication, and phenytoin, carbamezepine, and phenobarbital toxicity.

SIGNS AND SYMPTOMS

Dermatologic

Rashes and urticaria may develop.

Gastrointestinal

• Constipation is most common.
• Patient may also develop diarrhea, indigestion, or mechanical obstruction of gastrointestinal tract (sucralfate bezoar or "sucralith").

Fluids and Electrolytes

In patients on dialysis, aluminum toxicity may occur.

Musculoskeletal

In patients on dialysis, aluminum toxicity may occur, including osteodystrophy, bone pain, and bone microfractures.

Neurologic

In patients on dialysis, aluminum toxicity may occur, including dysarthria, acute encephalopathy, myoclonic jerks, and seizures.

PROCEDURES AND LABORATORY TESTS

Essential Tests

No tests are usually needed on asymptomatic patients.

Recommended Tests

• Aluminum level
  • The aluminum level should be measured in dialysis patients demonstrating signs of aluminum toxicity.
  • Aluminum levels may be obtained on blood, water, and dialysate, most commonly by atomic absorption.
  • Normal serum levels are less than 15 µg/L.
• Barium swallow may help diagnose sucralfate bezoars.
• ECG, serum acetaminophen and aspirin in overdose setting to detect occult ingestion.

Section Outline:

• DIFFERENTIAL DIAGNOSIS
• SIGNS AND SYMPTOMS
  • Dermatologic
  • Gastrointestinal
  • Fluids and Electrolytes
  • Musculoskeletal
  • Neurologic
• PROCEDURES AND LABORATORY TESTS
  • Essential Tests
  • Recommended Tests

• Treatment should focus on supportive care with appropriate airway management.
• Dose and time of ingestion should be determined for all substances involved.

DIRECTING PATIENT COURSE

The health-care professional should call the poison control center when:

• Severe or persistent effects develop.
• Coingestant, drug interaction, or underlying disease presents an unusual problem.

The patient should be referred to a health-care facility when:

• Suicide or homicide attempt is possible.
• Toxic effects develop.
• Coingestant, drug interaction, or underlying disease presents an unusual problem.

Admission Considerations

Dialysis patients exhibiting signs of aluminum require intensive care monitoring.

DECONTAMINATION

Out of Hospital

Induction of emesis is not recommended due to low toxic potential.

In Hospital

Gastric lavage and activated charcoal administration are not needed due to the benign nature of overdose.

ANTIDOTES

Dialysis patients may require deferoxamine chelation therapy for aluminum toxicity, related encephalopathy, and bone demineralization.

ADJUNCTIVE TREATMENT

Oral calcium carbonate may be substituted for aluminum- or magnesium-containing phosphate binders to prevent or treat aluminum toxicity.

Section Outline:

• DIRECTING PATIENT COURSE
  • Admission Considerations
• DECONTAMINATION
  • Out of Hospital
  • In Hospital
• ANTIDOTES
• ADJUNCTIVE TREATMENT

PATIENT MONITORING

Aluminum levels must be followed for end-stage renal patients on dialysis who are using sucralfate.

EXPECTED COURSE AND PROGNOSIS

Sucralfate ingestions are typically benign in patients with normal renal function.

DISCHARGE CRITERIA/INSTRUCTIONS

Discharge asymptomatic patients from the emergency department or hospital following decontamination and psychiatric evaluation, if needed.

Section Outline:

• PATIENT MONITORING
• EXPECTED COURSE AND PROGNOSIS
• DISCHARGE CRITERIA/INSTRUCTIONS

Failure to consider aluminum toxicity as an etiology of dementia in patients with renal failure

TREATMENT

Use in end-stage renal failure patients may lead to aluminum toxicity, especially if these patients are taking other aluminum-containing medicines.

Poisoning by agents primarily affecting skin and mucous membrane, ophthalmological, otorhinolaryngological, and dental drugs: emollients, demulcents, and protectants.

See Also: SECTION III, Deferoxamine chapter.

RECOMMENDED READING

McCarthy DM. Sucralfate. N Engl J Med 1991;325:1017-1025.

Author: Kathleen Graham

Reviewer: Gerald F. O'Malley