bismuth subsalicylate

Therapeutic Classification: antidiarrheals, antiulcer agents

Pharmacologic Classification: adsorbents

Indications ⬆ ⬇

REMS

Mild to moderate diarrhea.
Nausea, abdominal cramping, heartburn, and indigestion that may accompany diarrheal illnesses.
Treatment of ulcer disease associated with
Helicobacter pylori
(with anti-infectives).
Treatment/prevention of traveler’s (enterotoxigenic
Escherichia coli
) diarrhea.

Action ⬆ ⬇

Promotes intestinal adsorption of fluids and electrolytes.
Decreases synthesis of intestinal prostaglandins.

Therapeutic effects:

Relief of diarrhea.
Eradication of H. pylori with decreased recurrence of ulcer disease (with other agents).

Pharmacokinetics ⬆ ⬇

Absorption: Bismuth is not absorbed; salicylate split from parent compound is >90% absorbed from the small intestine.

Distribution: Salicylate is well distributed to tissues.

Protein Binding: Bismuth and salicylate >90%.

Metabolism/Excretion: Bismuth is excreted unchanged in the feces. Salicylate undergoes extensive hepatic metabolism.

Half-Life: Salicylate—2–3 hr for low doses; 15–30 hr with larger doses.

Time/Action Profile ⬆ ⬇

(relief of diarrhea and other GI symptoms)

ROUTE	ONSET	PEAK	DURATION
PO	within 24 hr	unknown	unknown

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Aspirin hypersensitivity; cross-sensitivity with NSAIDs or oil of wintergreen may occur;Pedi: During or after recovery from chickenpox or flu-like illness (contains salicylate, which can cause Reye syndrome);
OB: Pregnancy;
Lactation: Lactation.

Use Cautiously in:

Patients undergoing radiologic examination of the GI tract (bismuth is radiopaque);
Diabetes mellitus;
Gout;
Pedi: Potential for impaction in children and older adults.

Adv. Reactions/Side Effects ⬆ ⬇

GI: constipation, gray-black stools/tongue, impaction (infants, debilitated patients)

Interactions ⬆ ⬇

Drug-drug:

If taken with aspirin, may ↑ the risk of salicylate toxicity.
May ↓ absorption of tetracycline or fluoroquinolones (separate administration by 2–4 hr).
May ↓ effectiveness of probenecid (large doses).

Route/Dosage ⬆ ⬇

PO (Adults ): Antidiarrheal: 2 tablets or 30 mL (15 mL of extra/maximum strength) every 30 min or 2 tablets every 60 min as needed (not to exceed 4.2 g/24 hr). Antiulcer: 524 mg 4 times daily (as 2 tablets, 30 mL of regular strength suspension or 15 mL of extra/maximum strength).
PO (Children 9–12 yr): 1 tablet or 15 mL (7.5 mL of extra/maximum strength) every 30–60 min (not to exceed 2.1 g/24 hr).
PO (Children 6–9 yr): 10 mL (5 mL of extra/maximum strength) every 30–60 min (not to exceed 1.4 g/24 hr).
PO (Children 3–6 yr): 5 mL (2.5 mL of extra/maximum strength) every 30–60 min (not to exceed 704 mg/24 hr).

Availability ⬆ ⬇

(Generic available)

Tablets: 262 mg^OTC
Chewable tabletscherry and other flavors: 262 mg^OTC
Liquidcherry, caramel, peppermint, and other flavors: 262 mg/15 mL^OTC; 525 mg/15 mL^OTC
In combination with: metronidazole and tetracycline (Pylera—combination capsule). See Appendix [not included in this PDA edition].

Assessment ⬆ ⬇

Diarrhea: Assess the frequency and consistency of stools, presence of nausea and indigestion, and bowel sounds before and during therapy.
Assess fluid and electrolyte balance and skin turgor for dehydration if diarrhea is prolonged.
Ulcers: Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.

Lab Test Considerations:

Chronic high doses may cause falsely ↑ uric acid levels with colorimetric assay.
- May interfere with radiologic examination of the GI tract.
- May cause abnormal results with alkaline phosphatase, AST, and ALT tests.
- May cause ↓ potassium levels and serum T₃ and T₄ concentrations.
- Large doses of salicylates may also cause prolonged prothrombin time.

Implementation ⬆ ⬇

PO: Shake liquid before using. Chewable tablets may be chewed or allowed to dissolve before swallowing.

Patient/Family Teaching ⬆ ⬇

Instruct patient to take medication exactly as directed.
- Inform patient that medication may temporarily cause stools and tongue to appear gray-black.
- Instruct patient that this medication contains aspirin. Advise patient taking concurrent aspirin products to discontinue bismuth subsalicylate if tinnitus, ringing in the ears, occurs.
Diarrhea: Instruct patient to notify health care professional if diarrhea persists for more than 2 days or if accompanied by a high fever.
U.S. Centers for Disease Control and Prevention warn against giving salicylates to children or adolescents with varicella (chickenpox) or influenza-like or viral illnesses because of a possible association with Reye syndrome.
Ulcers: Advise patient to consult health care professional before taking other OTC ulcer remedies concurrently with bismuth subsalicylate.
Rep: Avoid bismuth subsalicylate during pregnancy and breastfeeding.

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Pronunciation ⬇

Classifications ⬆ ⬇