Bismuth subsalicylate is a medication commonly used to treat gastrointestinal issues such as diarrhea, indigestion, and upset stomach. It's the active ingredient in several over-the-counter products like Pepto-Bismol. Bismuth subsalicylate works by coating the stomach lining and reducing irritation, as well as by having antibacterial effects against certain pathogens that can cause diarrhea. It's often used to relieve symptoms of conditions like traveler's diarrhea or mild gastroenteritis.

Bismuth subsalicylate (Bismol) has got antisecretory, anti-inflammatory, and anti-diarrheal properties. It is used to treat the following conditions:

• For the symptomatic treatment of diarrhea.
• For the treatment of indigestion, relief of gas, heartburn, upset stomach, and nausea.
• As a part of combination therapy for the eradication of H.pylori infection.
• For the treatment and prophylaxis of travelers diarrhea.

Bismuth subsalicylate Dose in Adults

Bismuth subsalicylate Dose in the treatment of dyspepsia and diarrhoea:

• You can take about 524 milligrams by mouth every half to one hour, or 1,050 milligrams every hour, as needed for up to two days.
• But don't take more than 4,200 milligrams in a day for regular strength or 4 doses for maximum strength.

Bismuth subsalicylate Dose in the prophylaxis of traveler's diarrhea (off-label use):

• You'd take about 524 milligrams by mouth four times a day with meals and at bedtime during the time you're at risk of getting sick while traveling.

It's important to note that it's not safe to use it for more than three weeks continuously. Some experts even suggest avoiding it for trips longer than two weeks.

Bismuth subsalicylate the following dosage is for the treatment of traveler's diarrhea (off-label use):

• You'd take about 524 milligrams by mouth every 30 to 60 minutes as needed, up to 8 doses in a day.
•  It can help ease symptoms like diarrhea while you're traveling.

Bismuth subsalicylate off-label use as a component of an overall treatment plan for the elimination of Helicobacter pylori infection:

• According to the American College of Gastroenterology guidelines, one treatment approach is bismuth quadruple therapy.
• This involves taking 300 milligrams of bismuth subsalicylate orally four times a day, along with tetracycline 500 milligrams four times a day, metronidazole 500 milligrams three or four times a day (or 250 milligrams four times a day), and a standard-dose proton pump inhibitor twice daily.
• This regimen is typically continued for 10 to 14 days to help eradicate the H.pylori bacteria from the stomach.

Bismuth subsalicylate Dose in Children

Note:

• Bismuth subsalicylate is used to treat various stomach problems but it's important to be careful with the concentration of the liquid form.
• If you're ordering or giving it, make sure you check the concentration closely.
• Also, kids and teens who have or are getting over chickenpox or flu-like symptoms shouldn't use it because of the risk of Reye syndrome.
• Always check the label to see if it's okay for children and how much to give them.
• Dosing is usually measured in milligrams of bismuth subsalicylate.

Bismuth subsalicylate Dose in the treatment of diarrhoea:

For children aged 3 to under 12 years, the dosing of bismuth subsalicylate for diarrhea depends on their age:

• For ages 3 to under 6 years, they can take 87 milligrams orally every 30 minutes to 1 hour as needed.
• For ages 6 to under 9 years, the dose is 175 milligrams orally every 30 minutes to 1 hour as needed.
• For ages 9 to under 12 years, they can take 262 milligrams orally every 30 minutes to 1 hour as needed.
• For children aged 12 years and older, as well as adolescents, the dosage shouldn't exceed 8 doses in 24 hours for regular strength or 4 doses in 24 hours for maximum strength. They can take 524 milligrams orally every 30 minutes to 1 hour as needed for regular strength or 1,050 milligrams orally every hour as needed for maximum strength. Always follow the instructions and don't exceed the recommended dosage.

Bismuth subsalicylate Dose in the treatment of dyspepsia:

For children aged 12 years and older, and adolescents:

• Regular strength: Take 524 milligrams orally every 30 minutes to 1 hour as needed. Don't take more than 8 doses in 24 hours.
• Maximum strength: Take 1,050 milligrams orally every 1 hour as needed. But don't take more than 4 doses in 24 hours. It's essential to stick to these guidelines and not exceed the recommended dosage.

Bismuth subsalicylate Dose in the treatment of chronic diarrhea:

• Infants aged 2 months and older: Take 44 milligrams orally every 4 to 6 hours.
• Children under 2 years old: Take 44 milligrams orally every 4 hours or 87 milligrams every 6 hours.
• Children aged 2 to under 3 years: Take 87 milligrams orally every 4 to 6 hours.
• Children aged 3 to under 4 years: Take 87 milligrams orally every 4 hours.
• Children aged 4 to 6 years: Take 175 milligrams orally every 4 hours.

These dosage recommendations are based on limited data. Studies have shown that bismuth subsalicylate can help improve symptoms of chronic diarrhea in infants and children. It's important to follow the prescribed dosage and duration of treatment as advised by a healthcare professional. Some studies suggest tapering off the medication at the end of therapy to prevent symptom recurrence.

Bismuth subsalicylate dose in the treatment of Helicobacter pylori-associated antral gastritis (as part of combination therapy):

• Children and Adolescents: Take 8 milligrams per kilogram of body weight per day orally, divided into two doses daily, for 10 to 14 days. In some pediatric trials, the doses were divided into four times daily.

This treatment is usually part of triple or quadruple therapy for Helicobacter pylori-associated antral gastritis. It's essential to follow the prescribed dosage and duration of treatment as advised.

Pregnancy Risk Factor: C

• Bismuth subsalicylate breaks down into bismuth and salicylic acid in the stomach.
• Salicylates, like those found in aspirin, can pass through the placenta after being taken orally.
• However, very little bismuth gets absorbed into the body from this medication.
• The amount of salicylic acid in the bloodstream can be similar to what's seen after taking aspirin.
• It's important to note that bismuth subsalicylate shouldn't be used for treating sudden diarrhea, and guidelines advise against using it for traveler's diarrhea during pregnancy.
• For more information about the effects of salicylates during pregnancy, you can refer to information on aspirin.

Use of bismuth subsalicylates during breastfeeding

• Salicylates, including those from bismuth subsalicylate, can pass into breast milk.
• After taking bismuth subsalicylate, the amount of salicylic acid in the bloodstream can be similar to what's seen after taking aspirin.
• It's not clear if bismuth itself is present in breast milk, but when bismuth subsalicylate is taken orally at typical doses, only a small amount is absorbed into the body.
• There's a case report of a baby who had bowel obstruction after their breastfeeding mother used a bismuth-containing ointment on her nipples.
• Because of these concerns, it's recommended not to use bismuth subsalicylate for treating or preventing traveler's diarrhea while breastfeeding.
• For more information about salicylates and breastfeeding, you can refer to information about aspirin.

Bismuth subsalicylate Dose in Renal Disease:

• No adjustments to the dosage of bismuth subsalicylate have been suggested by the manufacturer for patients with kidney disease.

Bismuth subsalicylate Dose in Liver Disease:

• There have been no recommendations from the manufacturer to adjust the dosage of bismuth subsalicylate for patients with liver disease.

Side Effects Frequency not defined

• Central Nervous System:
  • Anxiety
  • Confusion
  • Depression
  • Headache
  • Slurred Speech
• Neuromuscular & Skeletal:
  • Muscle Spasm
  • Weakness
• Gastrointestinal:
  • Grayish black faecal Discoloration
  • Tongue Discoloration
• Otic:
  • Hearing Loss
  • Tinnitus

Contraindications to bismuth subsalicylate include:

• When using bismuth subsalicylate for self-medication, it's important to follow the over-the-counter labeling.
• This means not using it if you're allergic to salicylates or currently taking other medications containing salicylates.

Warnings and Precautions

Neurotoxicity:

• Bismuth products can potentially cause neurotoxicity when taken in very large doses.
• This means that if you take an excessive amount of bismuth-containing medications, it could have harmful effects on your nervous system.

Bismuth subsalicylate: Drug Interaction

How to take bismuth subsalicylate

For Oral Use

• Shake Liquids Well: Before using liquid forms of the medication, make sure to shake them well. This helps ensure that the medicine is evenly mixed and ready for use.
• Chew Thoroughly or Allow Dissolving: If you're taking chewable tablets, it's important to chew them thoroughly before swallowing. If you're using tablets that are meant to dissolve in the mouth, let them dissolve completely before swallowing. This ensures that you get the full dose of the medication.
• Swallow Nonchewable Tablets Whole: For tablets that are not meant to be chewed, swallow them whole with a full glass of water. This helps the tablet reach your stomach intact so that the medicine can be absorbed properly.

Mechanism of action of Bismuth subsalicylate:

• Bismuth subsalicylate does two main things: it helps reduce stomach secretions and fights off germs in the gut.
• The part of the medication that's like aspirin helps reduce stomach secretions, which can help with issues like diarrhea.
• The bismuth part of the medicine fights against bacteria and viruses that cause stomach problems directly.
• It might also have some anti-inflammatory effects, which can help calm down inflammation in the stomach.

Absorption

• Bismuth: Less than 1% of bismuth from bismuth subsalicylate is absorbed into the bloodstream.
• Subsalicylate: Over 80% of the subsalicylate component is absorbed in the gastrointestinal tract.

Distribution

• Salicylate: The volume of distribution for salicylate is approximately 170 milliliters per kilogram (mL/kg) of body weight.

Protein Binding

• Bismuth and Salicylate: Both bismuth and salicylate are highly bound to proteins in the plasma, with over 90% bound.

Metabolism

• Bismuth subsalicylate is broken down in the gastrointestinal tract into bismuth and salicylic acid.

Half-life Elimination

• Bismuth: The terminal half-life of bismuth ranges from 21 to 72 days.
• Salicylate: The terminal half-life of salicylate ranges from 2 to 5 hours.

Excretion

• Bismuth: Bismuth is excreted primarily in urine and bile.
• Salicylate: Salicylate is excreted mainly in urine, with approximately 10% excreted unchanged.

International Brands of Bismuth Subsalicylate:

• Bismatrol Maximum Strength
• Bismatrol
• Diotame
• Geri-Pectate
• Kao-Tin
• Peptic Relief
• Pepto-Bismol InstaCool
• Pepto-Bismol
• Pink Bismuth
• Stomach Relief Max St
• Stomach Relief
• Bisbacter
• Bismucar
• Bismutol
• Bitni X Forte Suspension
• Facidmol
• Gastro-Bismol
• Gastro-Bismol L
• Kalbeten
• Peptolite
• Pink Bismuth
• Stobiol

Bismuth subsalicylate brands in Pakistan: