What is the role of sucralfate in the treatment of Gastroesophageal Reflux Disease (GERD)?

Role of Sucralfate in the Treatment of Gastroesophageal Reflux Disease (GERD)

Sucralfate is not recommended as a primary treatment for GERD as it has been superseded by more effective medications such as PPIs and H2RAs, and may even worsen some gastrointestinal symptoms. 1

Current Treatment Approach for GERD

First-Line Therapy

1. Lifestyle and Dietary Modifications

   • Weight management for overweight/obese patients
   • Avoiding trigger foods and limiting fat intake
   • Elevating head of bed for nocturnal symptoms
   • Avoiding meals within 3 hours of bedtime

2. Pharmacologic Therapy

   • Proton Pump Inhibitors (PPIs): 4-8 week trial of single-dose PPI as first-line medication 1, 2
   • If inadequate response, increase to twice daily dosing or switch to a more effective PPI 1

Adjunctive Therapy for Refractory GERD

For patients with persistent symptoms despite PPI therapy, the following adjunctive options are recommended:

• Alginate-antacid combinations: Particularly useful for post-prandial symptoms and in patients with hiatal hernia 1, 2
• H2-receptor antagonists (H2RAs): Helpful for breakthrough and nighttime symptoms 1
• Baclofen: May be effective for belch-predominant symptoms and mild regurgitation 1
• Prokinetics: Consider in patients with concomitant gastroparesis 1

Evidence on Sucralfate in GERD

Sucralfate has been evaluated in GERD based on its:

• Protective adherence to denuded surfaces
• Bile salt-binding properties
• Cytoprotective properties 3

Efficacy Evidence

• Some older studies (1987-1996) showed that sucralfate improved symptoms and reduced severity of reflux esophagitis comparable to cimetidine 3, 4
• When used as adjunctive therapy with cimetidine, sucralfate suspension showed improvement in daytime heartburn symptoms and better overall endoscopic outcomes compared to cimetidine alone 5
• A 1996 study demonstrated superiority of sucralfate gel over placebo in non-erosive GERD 6

Limitations and Concerns

• More recent guidelines do not recommend sucralfate as a primary treatment for GERD
• Studies investigating sucralfate for prevention of radiation therapy-induced diarrhea showed mixed results, with some suggesting it may aggravate GI symptoms 1
• Current guidelines from the American Gastroenterological Association and other societies do not include sucralfate in their primary treatment algorithms for GERD 1, 2

Special Considerations

Pregnancy

In pregnancy, sucralfate is positioned in the treatment algorithm after lifestyle modifications and antacids, but before H2RAs and PPIs 2

Refractory GERD

For patients with persistent symptoms despite optimal PPI therapy:

1. Consider diagnostic testing (endoscopy, pH monitoring, manometry)
2. Add adjunctive therapy based on symptom pattern
3. Consider surgical options for confirmed refractory GERD

Conclusion

While sucralfate showed some efficacy in older studies, current evidence and guidelines do not support its use as a primary treatment for GERD. Modern treatment algorithms focus on PPIs as first-line therapy, with specific adjunctive medications based on symptom patterns. Sucralfate may have a limited role in specific situations such as pregnancy, but is not routinely recommended for general GERD management.