Can sucralfate be given to patients with impaired renal function?

Sucralfate Use in Renal Failure

Sucralfate should be used with caution in patients with chronic renal failure due to the risk of aluminum accumulation and toxicity. 1

Mechanism of Concern

Sucralfate contains aluminum, which is normally excreted by the kidneys. In patients with impaired renal function:

• Small amounts of aluminum are absorbed from the gastrointestinal tract when sucralfate is administered orally 1
• Patients with chronic renal failure have impaired excretion of absorbed aluminum 1
• Aluminum does not cross dialysis membranes because it is bound to albumin and transferrin plasma proteins 1
• Long-term accumulation can lead to aluminum toxicity (aluminum osteodystrophy, osteomalacia, encephalopathy) 1, 2

Evidence on Aluminum Absorption and Accumulation

• Studies show measurable quantities of aluminum are absorbed after administration of sucralfate, with absorption rates of approximately 0.005% of the administered dose 3
• In patients with chronic renal failure, serum aluminum levels increase significantly by day 2 of sucralfate therapy and remain elevated 2
• The elimination half-life of serum aluminum after therapeutic dosing of sucralfate in renal failure patients is approximately 13.1 ± 3.1 days 2
• Serum aluminum levels are significantly higher in patients with chronic renal failure compared to those with normal renal function after sucralfate administration 2

Recommendations for Use in Renal Failure

1. Short-term use:

   • Short-term use may be considered with careful monitoring of serum aluminum levels 4
   • Monitor for signs of aluminum toxicity during therapy 1

2. Long-term use:

   • Long courses of sucralfate should be used with caution or avoided in chronic renal failure 2
   • The risk of toxicity most likely represents a long-term complication of sucralfate use in this patient population 4

3. Monitoring:

   • Patients with renal failure undergoing prolonged sucralfate therapy should be monitored for potential signs of aluminum toxicity 4
   • Serum phosphorus should be checked routinely in patients treated with sucralfate 5

Potential Benefits in Renal Failure

Interestingly, sucralfate has been shown to have some beneficial effects in patients with chronic renal failure:

• Significant reduction in serum phosphorus and alkaline phosphatase 5
• Increase in serum calcium 5
• May help in treatment of hyperphosphatemia and secondary hyperparathyroidism in chronic renal failure 5, 6

Important Precautions

• Avoid concomitant use with other aluminum-containing medications (such as aluminum-containing antacids, phosphate binders, or antidiarrheal preparations) 1, 4
• If other medications are needed, administer them 2 hours before sucralfate to avoid drug interactions 1
• Be aware that sucralfate may reduce the bioavailability of certain drugs including phenytoin, fluoroquinolone antibiotics, and H2-receptor blockers 6

Conclusion

While sucralfate can be used in patients with renal failure, it requires careful consideration of risks versus benefits. For short-term use, the benefits may outweigh the risks, but long-term use should be approached with caution due to the potential for aluminum accumulation and toxicity.