Medical term:

Pepto

bismuth subsalicylate

Bismatrol, Bismatrol Maximum Strength, Diotame, Kao-Tin, Kaopectate, Kaopectate Extra Strength, Kapectolin, Maalox Total Stomach Relief, Pepto-Bismol, Pepto-Bismol Bismuth Maximum Strength, Pink Bismuth

Pharmacologic class: Adsorbent

Therapeutic class: Antidiarrheal, antibiotic, antiulcer drug

Pregnancy risk category C

Action

Promotes intestinal adsorption of fluids and electrolytes and decreases synthesis of intestinal prostaglandins. Adsorbent action removes irritants from stomach and soothes irritated bowel lining. Also shows antibacterial activity to eradicate Helicobacter pylori.

Availability

Liquid: 130 mg/15 ml, 262 mg/15 ml, 525 mg/15 ml (maximum strength)

Tablets: 262 mg

Tablets (chewable): 262 mg, 300 mg

Indications and dosages

➣ Adjunctive therapy for mild to moderate diarrhea, nausea, abdominal cramping, heartburn, and indigestion accompanying diarrheal illnesses

Adults: Two tablets or 30 ml P.O. (15 ml of maximum strength) q 30 minutes, or two tablets or 60 ml (30 ml of extra/maximum strength) q 60 minutes as needed. Don't exceed 4.2 g in 24 hours.

Children ages 9 to 12: One tablet or 15 ml P.O. (7.5 ml of maximum strength) q 30 to 60 minutes. Don't exceed 2.1 g in 24 hours.

Children ages 6 to 9: 10 ml (5 ml of maximum strength) P.O. q 30 to 60 minutes. Don't exceed 1.4 g in 24 hours.

Children ages 3 to 6: 5 ml (2.5 ml of maximum strength) P.O. q 30 to 60 minutes. Don't exceed 704 mg in 24 hours.

➣ Ulcer disease caused by H. pylori

Adults: Two tablets or 30 ml P.O. q.i.d. (15 ml of maximum strength)

Off-label uses

• Chronic infantile diarrhea

• Norwalk virus-induced gastroenteritis

Contraindications

• Hypersensitivity to aspirin

• Elderly patients with fecal impaction

• Children or adolescents during or after recovery from chickenpox or flulike illness

Precautions

Use cautiously in:

• diabetes mellitus, gout

• patients taking concurrent aspirin

• elderly patients

• pregnant or breastfeeding patients

• infants.

Administration

• Know that tablets should be chewed or dissolved in mouth before swallowing.

• Be aware that drug is usually given with antibiotics (such as tetracycline or amoxicillin) when prescribed for ulcer disease.

Adverse reactions

EENT: tinnitus, tongue discoloration

GI: nausea, vomiting, diarrhea, constipation, gray-black stools, fecal impaction

Respiratory: tachypnea

Other: salicylate toxicity

Interactions

Drug-drug. Aspirin, other salicylates: salicylate toxicity

Corticosteroids, probenecid (large doses),

sulfinpyrazone: decreased bismuth efficacy

Enoxacin: decreased enoxacin bioavailability

Methotrexate: increased risk of bismuth toxicity

Tetracycline: decreased tetracycline absorption

Drug-diagnostic tests. Radiologic GI tract examination: test interference

Patient monitoring

• Monitor fluid intake and electrolyte levels.

• Monitor stool frequency and appearance.

• Assess infants and debilitated patients for fecal impaction.

Patient teaching

• Instruct patient to chew tablets or dissolve them in mouth before swallowing.

• Inform patient that drug may turn stools gray-black temporarily.

• Tell patient to notify prescriber if he has diarrhea with fever for more than 48 hours.

• As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

bismuth subsalicylate

(biz-muth sub-sa-lis-i-late ) ,

Bismatrol

(trade name),

Kaopectate

(trade name),

Kao-Tin

(trade name),

Kapectolin

(trade name),

Peptic Relief

(trade name),

Pepto-Bismol

(trade name)

Classification

Therapeutic: antidiarrheals
Pharmacologic: adsorbents

Pregnancy Category: C

Indications

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.Chronic infantile 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. Salicylate is highly bound to albumin.

Distribution: Salicylate crosses the placenta and enters breast milk.

Metabolism and 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

Contraindications/Precautions

Contraindicated in: Aspirin hypersensitivity; cross-sensitivity with NSAIDs or oil of wintergreen may occur. Pediatric: During or after recovery from chickenpox or flu-like illness (contains salicylate, which can cause Reye's syndrome); Geriatric: Geriatric patients who may have fecal impaction.

Use Cautiously in: Patients undergoing radiologic examination of the GI tract (bismuth is radiopaque);Diabetes mellitus;Gout; Obstetric / Lactation: Safety not established; avoid chronic use of large doses; Pediatric / Geriatric: Potential for impaction.

Adverse Reactions/Side Effects

Gastrointestinal

constipation
gray-black stools
impaction (infants, debilitated patients)

Interactions

Drug-Drug interaction

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

Oral (Adults) Antidiarrheal—2 tablets or 30 mL (15 mL of extra/maximum strength) q 30 min or 2 tablets q 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).

Oral (Children 9–12 yr) 1 tablet or 15 mL (7.5 mL of extra/maximum strength) q 30–60 min (not to exceed 2.1 g/24 hr).

Oral (Children 6–9 yr) 10 mL (5 mL of extra/maximum strength) q 30–60 min (not to exceed 1.4 g/24 hr).

Oral (Children 3–6 yr) 5 mL (2.5 mL of extra/maximum strength) q 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, 300 mg^OTC

Liquidcherry, caramel, peppermint, and other flavors: 262 mg/15 mL^OTC, 264 mg/15 mL^OTC, 525 mg/15 mL^OTC

In combination with: metronidazole and tetracycline (Helidac—convenience package) (Pylera—combination capsule). See combination drugs.

Nursing implications

Nursing 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 (PT).
- For additional lab test considerations related to salicylate content, see salicylates monograph.

Potential Nursing Diagnoses

Diarrhea (Indications)
Constipation (Side Effects)

Implementation

Do not confuse Kaopectate (bismuth subsalicylate) with Kaopectate Stool Softener (docusate calcium).
Oral: 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’s syndrome.
Ulcers: Advise patient to consult health care professional before taking other OTC ulcer remedies concurrently with bismuth subsalicylate.

Evaluation/Desired Outcomes

Decrease in diarrhea.
Decrease in symptoms of indigestion.
Prevention of traveler’s diarrhea.
Treatment of ulcers.

Pepto-Bismol

(pĕp′tō-bĭz′môl)

A trademark for a preparation of bismuth subsalicylate.

Peptococcus

[pep″to-kok´us]

a genus of gram-positive, anaerobic, coccoid bacteria; they are part of the flora of the mouth, upper respiratory tract, and large intestine, and also cause soft tissue infection and bacteremias. P. mag´nus is the species most often recovered from clinical specimens.

Peptococcus

(pep'tō-kok'ŭs),

A genus of nonmotile, anaerobic, chemoorganotrophic bacteria (family Peptococcaceae) containing gram-positive, spheric cells that occur singly, in pairs, tetrads, or irregular masses, and rarely in short chains. They are frequently found in association with pathologic conditions. The type species is Peptococcus niger.

[G. peptō, to digest, + kokkos, berry]

Pep·to·coc·cus

(pep'tō-kok'ŭs)

A genus of nonmotile, anaerobic, chemoorganotrophic bacteria containing gram-positive, spheric cells that occur singly, in pairs, tetrads, or irregular masses, more rarely in short chains. They are frequently found in association with pathologic conditions. The type species is niger.

[G. peptō, to digest, + kokkos, berry]

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