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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


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.


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


• Hypersensitivity to aspirin
• Elderly patients with fecal impaction
• Children or adolescents during or after recovery from chickenpox or flulike illness


Use cautiously in:
• diabetes mellitus, gout
• patients taking concurrent aspirin
• elderly patients
• pregnant or breastfeeding patients
• infants.


• 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


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 ) ,


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Peptic Relief

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Therapeutic: antidiarrheals
Pharmacologic: adsorbents
Pregnancy Category: C


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.


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).


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)

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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


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


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).


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 mgOTC
Chewable tabletscherry and other flavors: 262 mgOTC, 300 mgOTC
Liquidcherry, caramel, peppermint, and other flavors: 262 mg/15 mLOTC, 264 mg/15 mLOTC, 525 mg/15 mLOTC
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)


  • 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.


A trademark for a preparation of bismuth subsalicylate.
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To help avoid traveler's diarrhea, health experts recommend taking Pepto Bismol, two tablets four times a day starting the day before you leave and continuing daily until two days after returning home (side effects can include tinnitus, nausea and vomiting).