Bismuth subsalicylate (BSS) has been around for over 100 years and was first FDA approved in 1939. It was created prior to the practice of hygiene and sanitation for the cure of cholera infections. BSS has provided healthcare professionals with an alternative option to antibiotics for the treatment of nausea and diarrhea. The primary indications of BSS involve gastrointestinal conditions and traveler's diarrhea.
The FDA approved indications of BSS are for the treatment of diarrhea, heartburn, indigestions, nausea, and stomach upset. BSS is effective in situations where patients are experiencing mild gastrointestinal discomfort, as it reduces the severity and incidence of flatulence and diarrhea. BSS, in comparison to a placebo, was able to provide greater and faster relief in patients with mild, moderate, and severe symptoms.  BSS can be found over the counter and does not require a prescription; as such, it has become a preferred self-treatment option for mild diarrhea, replacing the need for an antibiotic.
One off-label indication for BSS use is for the eradication of helicobacter pylori (H. pylori) gastrointestinal tract infection. When used as part of a quadruple therapy regimen containing a proton pump inhibitor, tetracycline, and metronidazole, the research has found that BSS eradicated up to 90% of H. pylori infections.
Another off-label indication for BSS is for the prophylaxis and treatment of traveler's diarrhea. In developing countries, traveler's diarrhea affects at least 20% to more than 50% of tourists. BSS demonstrated effectiveness in the acute treatment of traveler's diarrhea in patients with mild symptoms. A review article that included four different studies with a combination of N=2500 patients found that BSS was significantly superior to placebo for the treatment of travelers' diarrhea. Furthermore, BSS decreased stool frequency and time to symptom relief in comparison to placebo.
BSS may also be used to prevent traveler's diarrhea. However, its prophylactic efficacy was less than antibiotics (62% versus 80%, respectively). The frequency in the administration of BSS in multiple doses (three to four times daily) may compromise compliance and, as such, affect the rates of prevention of traveler's diarrhea. Although not particularly common, bismuth subsalicylate has also demonstrated effectiveness for the treatment of cholera in children.
BSS exhibits many of its properties due to its formulation as an insoluble salt of salicylic acid and trivalent bismuth. The mechanism of action through which BSS works is complex. In the stomach, BSS hydrolyzes into two compounds, bismuth, and salicylic acid. The salicylate compound is almost completely absorbed into the bloodstream, while bismuth salt is minimally absorbed. The bismuth that remains in the gastrointestinal tract forms other bismuth salts. These bismuth salts contain bactericidal antimicrobial activity and prevent bacteria from binding and growing on the mucosal cells of the stomach. This is the mechanism in which BSS helps eradicate H. pylori. Furthermore, the prevention of bacterial binding to the mucosal cells provides many benefits, which include prevention of intestinal secretion, promotion of fluid absorption, reduction of inflammation, and promotion of the healing of any present ulcer in the stomach.
It appears as though BSS does not alter the normal flora of the stomach, however, it's antimicrobial and antisecretory properties play a major role in combating diarrhea. The antidiarrheal effect of BSS is most likely due to:
While, in peptic ulcer disease, the likely mechanism of BSS involves its cytoprotective and demulcent activity. In H. pylori specifically, BSS blocks the adhesion of the bacteria to the gastric epithelial cells. Additionally, BSS inhibits H. pylori's enzyme activities, including phospholipase, protease, and urease.
Bismuth subsalicylate is administered orally and requires storage at room temperature. BSS is available in either suspension or tablet form. Patients (adults and children) should be advised to shake the suspension well before use and to utilize the enclosed dosage cup. The chewable tablets may be dissolved in the mouth or chewed and swallowed. However, non-chewable tablets should be swallowed whole and taken with water. The proper recommended dosage depends on the indication and the age of the patient. Of note, data for the use of BSS in pediatric patients less than 12 years old is limited.
The common adverse effects associated with the administration of bismuth subsalicylate are nausea, bitter taste, diarrhea, and dark/black stools. Although not common, bismuth toxicity can result from the overconsumption of bismuth subsalicylate over an extended period of time and can result in the blackening of the tongue and teeth, fatigue, mood changes, and deterioration of mental status.
Bismuth subsalicylate can be fatal in very rare circumstances and can lead to neurotoxicity. Other adverse effects with an unknown frequency of BSS include hearing loss or tinnitus, muscle spasms or weaknesses, anxiety, confusion, depression, headaches, and potentially slurred speech.
In patients with certain medical conditions, bismuth subsalicylate should not be used. BSS should be avoided in:
For patients with any of the listed conditions, the suggestion is that they use alternative treatment options. Patients should be cautious in using bismuth subsalicylate when traveling to countries where malaria is prevalent, as it can deplete the absorption of doxycycline, which is an effective antibiotic for prophylaxis against malaria.
Prior to the administration of BSS, the recommendation is to assess the patient's active medication therapies and the history of allergies. Dose adjustment of BSS or alternate treatment may be necessary depending on the patient's medical history. Patients should be counseled on the proper administration of BSS and what to do in cases where diarrhea symptoms persist. The therapeutic efficacy of BSS is demonstrated by the reduction in the number of unformed stools and the relief of symptoms. Most patients should see a positive therapeutic response within four hours of the ingestion of BSS. Toxicity of BSS is rare, as such salicylate plasma levels do not need to be monitored. In the cases where toxicity is suspected, follow-up monitoring at least 12 hours after the ingestion of salicylate products is recommended.
The most concerning adverse effect of BSS is salicylate toxicity. Although quite rare, bismuth toxicity can occur in patients. It primarily occurs in patients who have taken bismuth subsalicylate inappropriately, whether through an overdose or for extended periods of time. Symptoms of bismuth toxicity include impaired cognition, tremors, lethargy, somnolence, insomnia, delirium, myoclonus, seizures, depressed mood, anxiety, and a depressed mood. If a patient is experiencing bismuth toxicity, they should discontinue the use of BSS and seek medical attention. Fortunately, there is little evidence to suggest that bismuth subsalicylate can be fatal, although there have been a few reported cases.
Toxicity is generally seen in patients who ingest more than 150 mg/kg of salicylates (or > 6.5 g of aspirin equivalent). There are no specific antidotes for salicylate toxicity. However, the management of mild to moderate toxicity generally includes supportive care with intravenous fluids. If the patient presents within 2-hours of ingestion of BSS, decontamination with activated charcoal is strongly recommended. Salicylate absorption can be delayed, as such activated charcoal may also be considered after 2-hours of ingestion if the patient is in a normal mental state. It is recommended to check a salicylate level every 1 to 2 hours until a decline is observed. If the salicylate level is more than 30 mg/dL, the team should consider urine alkalization.
In more severe cases and with the presence of altered mental status and metabolic acidosis, hemodialysis may be considered. If the patient is not able to maintain their airway and intubation is required, precautions should be taken to avoid severe acidosis. It is recommended to follow-up with arterial blood gases closely and maintain the pre-intubation minute ventilation and low PCO2. Other laboratory parameters that are recommended to be collected include hepatic panel, INR/PTT, CBC, electrolytes, and serum creatinine (renal function tests).
In the United States, BSS is an over the counter product. Even though this agent is available without a prescription, the interprofessional healthcare team needs to be cognitive of the proper use of BSS and coordinate care to educate patients and monitor both efficacy and toxicity. Pharmacists can identify any drug-drug interactions with BSS and make recommendations on the findings to both the provider and the patient. Nurses and pharmacists can both play a major role in providing patient education about the proper use of BSS and informing the patient about common adverse effects. For instance, patients should be aware that the darkening of the stool or tongue with the use of BSS is temporary and harmless. However, patients should contact a healthcare provider before the ingestion of BSS if they develop fever or mucus in the stool. Furthermore, patients should discontinue the use of BSS if:
Finally, in the cases where toxicity is suspected, a consult to a toxicologist or a poison control center is encouraged to help manage the patient appropriately.
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