Version July 2025
Diarrhea/dyspepsia: Oral: ~524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed for up to 2 days (maximum: ~4,200 mg/24 hours).
Helicobacter pylori eradication (off-label use):
Optimized bismuth quadruple therapy: Oral: 300 mg 4 times daily in combination with tetracycline, metronidazole, and a proton pump inhibitor; continue regimen for 14 days (Ref).
Travelers' diarrhea, treatment: Oral: ~524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed (maximum: ~4,200 mg/24 hours) (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function:
CrCl ≥50 mL/minute: No dosage adjustment necessary (Ref).
CrCl <50 mL/minute: No dosage adjustment necessary; however, use with caution as salicylates can potentially worsen kidney function in patients dependent on prostaglandins to maintain glomerular filtration rate, salicylate toxicity can occur at lower doses in patients with kidney insufficiency compared to those with normal kidney function, and bismuth can accumulate with long-term use in patients with severe kidney dysfunction. Use the lowest effective dose and limit durations of therapy when clinically feasible (Ref).
Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2): Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Young patients (<55 years of age) admitted post trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematological malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Ref).
No dosage adjustment necessary (Ref).
Hemodialysis, intermittent (thrice weekly): Salicylate is unlikely to be significantly dialyzable at therapeutic serum concentrations since highly protein bound; however, at supratherapeutic concentrations, protein binding is saturated and salicylates are readily dialyzable (Ref). Bismuth undergoes limited dialytic clearance (Ref).
No dosage adjustment necessary; however, use should generally be avoided as salicylate toxicity can occur at lower doses in patients with kidney insufficiency compared to those with normal kidney function, and bismuth can accumulate with long-term use. If necessary, use the lowest effective dose for the shortest duration of time (Ref).
Peritoneal dialysis: No dosage adjustment necessary; however, use should generally be avoided as salicylate toxicity can occur at lower doses in patients with kidney insufficiency compared to those with normal kidney function, and bismuth can accumulate with long-term use. If necessary, use the lowest effective dose for the shortest duration of time (Ref).
CRRT: No dosage adjustment necessary; however, use should generally be avoided as salicylates can potentially worsen acute kidney injury (Ref).
PIRRT: No dosage adjustment necessary; however, use should generally be avoided as salicylates can potentially worsen acute kidney injury (Ref).
There are no dosage adjustments provided in the manufacturer’s labeling.
Refer to adult dosing.
(For additional information see "Bismuth subsalicylate: Pediatric drug information")
Note: Multiple concentrations of oral liquid formulations exist; close attention must be paid to the concentration when ordering or administering. Children and adolescents who have or are recovering from chicken pox or flu-like symptoms should not use bismuth subsalicylate due to the association with Reye syndrome. Refer to product-specific labeling for approved pediatric ages. Dosing presented as mg of bismuth subsalicylate.
Diarrhea, chronic (Ref): Limited data available: Oral liquid:
Infants ≥2 months: Oral: 44 mg every 4 to 6 hours.
Children <2 years: Oral: 44 mg every 4 hours or 87 mg every 6 hours.
Children 2 to <3 years: Oral: 87 mg every 4 to 6 hours.
Children 3 to <4 years: Oral: 87 mg every 4 hours.
Children 4 to 6 years: Oral: 175 mg every 4 hours.
Dosing based on 2 studies; the first was a prospective, double-blind, placebo-controlled clinical trial of 29 infants and children with chronic diarrhea (>6 weeks); after 7 days of bismuth therapy, patients in the treatment group (n=15, age 2 to 30 months) gained significantly more weight and had significantly improved stool characteristics (consistency/frequency) compared to placebo; to prevent recurrence of symptoms, the authors also suggested tapering the medication at the end of therapy (Ref). A second study compared bismuth subsalicylate with cholestyramine; patients were treated with bismuth (n=19) for 7 days; bismuth was found to be as effective as cholestyramine in binding of bile acids and at decreasing stool frequency (Ref).
Diarrhea, dyspepsia, acute (gas, upset stomach, indigestion, heartburn, nausea): OTC labeling:
Children ≥12 years and Adolescents: Oral: 524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed for up to 2 days. Maximum daily dose: 4,200 mg/day.
Travelers' diarrhea (Ref): Limited data available in children <12 years:
Children 3 to <6 years: Oral: 87 mg every 30 to 60 minutes as needed; do not exceed 8 doses per 24 hours.
Children 6 to <9 years: Oral: 175 mg every 30 to 60 minutes as needed; do not exceed 8 doses per 24 hours.
Children 9 to <12 years: Oral: 262 mg every 30 to 60 minutes as needed; do not exceed 8 doses per 24 hours.
Children ≥12 years and Adolescents: Oral: 524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed; maximum dose: 4,200 mg per 24 hours.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no adverse reactions listed in the manufacturer's labeling.
Postmarketing:
Gastrointestinal: Esophagitis (acute esophageal necrosis) (Abed 2014), melena (Bierer 1990), melanoglossia (Bierer 1990), staining of tooth (Borbinha 2019)
Hypersensitivity: Anaphylaxis (More 2002)
Nervous system: Encephalopathy (Borbinha 2019)
Otic: Tinnitus (Castelli 2006)
OTC labeling: When used for self-medication, do not use if you are allergic to salicylates (including aspirin) or are taking other salicylates; have an ulcer, bleeding problem or bloody/black stool.
Concerns related to adverse effects:
• Neurotoxicity: Bismuth products may be neurotoxic with very large doses.
Dosage forms
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer's labeling.
Other warnings/precautions:
• Diagnostic GI procedures: Bismuth absorbs x-rays and may interfere with diagnostic procedures of GI tract.
• Self-medication (OTC use): Pediatric patients who have or are recovering from chickenpox or flu-like symptoms should not use subsalicylate. Changes in behavior (along with nausea and vomiting) may be an early sign of Reye syndrome; patients should be instructed to contact their health care provider if these occur. A temporary harmless darkening of the stool and/or tongue may occur with use. Contact a health care provider before use if fever or mucus in the stool occurs. Discontinue use and contact health care provider if any of the following occur: diarrhea lasts >2 days, diarrhea with a fever, symptoms get worse, hearing loss, or ringing in the ears.
Do not use aspirin-containing products in children and adolescents who have or who are recovering from chickenpox or flu symptoms (due to the association with Reye syndrome); when using aspirin, changes in behavior (along with nausea and vomiting) may be an early sign of Reye syndrome; instruct patients and caregivers to contact their health care provider if these symptoms occur.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Suspension, Oral:
Bismatrol Maximum Strength: 525 mg/15 mL (236 mL [DSC]) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium]
Diotame InstyDose: 262 mg/15 mL (30 mL [DSC]) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium, salicylic acid]
FT Stomach Relief: 525 mg/30 mL (236 mL) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium, salicylic acid]
GoodSense Stomach Relief: 525 mg/30 mL (236 mL) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium, salicylic acid]
GoodSense Stomach Relief: 1050 mg/30 mL (236 mL) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium]
Kaopectate: 262 mg/15 mL (325 mL) [contains fd&c red #40 (allura red ac dye); peppermint flavor]
Pepto-Bismol: 262 mg/15 mL (118 mL) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium; original flavor]
Stomach Relief: 525 mg/15 mL (237 mL) [contains d&c red #22 (eosine), saccharin sodium]
Stomach Relief: 525 mg/30 mL (237 mL) [alcohol free, sugar free; contains benzoic acid, d&c red #22 (eosine)]
Stomach Relief Extra Strength: 525 mg/15 mL (237 mL) [alcohol free, sugar free; contains benzoic acid, d&c red #22 (eosine)]
Stomach Relief Plus: 525 mg/15 mL (240 mL, 480 mL)
Generic: 525 mg/30 mL (30 mL [DSC])
Suspension, Oral, as subsalicylate:
Pepto-Bismol: 262 mg/15 mL (473 mL) [contains benzoic acid, d&c red #22 (eosine), saccharin sodium]
Pink Bismuth: 262 mg/15 mL (236 mL)
Stomach Relief: 527 mg/30 mL (240 mL, 480 mL)
Tablet Chewable, Oral:
FT Stomach Relief: 262 mg [contains saccharin sodium]
GoodSense Stomach Relief: 262 mg [contains saccharin sodium]
Stomach Relief: 262 mg [contains aspartame]
Generic: 262 mg
Tablet Chewable, Oral, as subsalicylate:
Bismatrol: 262 mg [DSC] [contains saccharin sodium]
Diotame: 262 mg [DSC] [contains aspartame]
Peptic Relief: 262 mg [DSC] [contains saccharin sodium]
Pepto-Bismol To-Go: 262 mg [sugar free; contains fd&c red #40(allura red ac)aluminum lake, saccharin sodium; cherry flavor]
Generic: 262 mg
Yes
Chewable (Bismuth Subsalicylate Oral)
262 mg (per each): $0.08 - $0.09
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Oral: Shake liquids well prior to use. Chew tablets thoroughly or allow to dissolve in the mouth before swallowing. Nonchewable tablets should be swallowed whole with a full glass of water.
Oral:
Liquid: Shake well before using.
Tablets, chewable: Chew or allow to dissolve in mouth before swallowing.
Tablets, nonchewable caplets: Swallow whole with a full glass of water.
Diarrhea: Relief of diarrhea.
Dyspepsia: Relief of upset stomach, including belching, fullness, gas, indigestion, heartburn, and nausea.
Travelers’ diarrhea, treatment: Relief of travelers’ diarrhea.
Helicobacter pylori eradication; Travelers' diarrhea, prophylaxis
Kaopectate may be confused with Kayexalate
KIDs List: Salicylates, when used in pediatric patients <18 years of age with suspicion of viral illness (influenza, chickenpox), are identified on the Key Potentially Inappropriate Drugs in Pediatrics (KIDs) list and should be used with caution due to risk of Reye syndrome (weak recommendation; very low quality of evidence) (PPA [Meyers 2020]).
Canadian formulation of Kaopectate does not contain bismuth; the active ingredient in the Canadian formulation is attapulgite.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Agents with Blood Glucose Lowering Effects: Salicylates may increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Ajmaline: Salicylates may increase adverse/toxic effects of Ajmaline. Specifically, the risk for cholestasis may be increased. Risk C: Monitor
Ammonium Chloride: May increase serum concentration of Salicylates. Risk C: Monitor
Angiotensin-Converting Enzyme Inhibitors: Salicylates may decrease therapeutic effects of Angiotensin-Converting Enzyme Inhibitors. Salicylates may increase nephrotoxic effects of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor
Anticoagulants: Salicylates may increase anticoagulant effects of Anticoagulants. Risk C: Monitor
Benzbromarone: Salicylates may decrease therapeutic effects of Benzbromarone. Risk C: Monitor
Bismuth Subcitrate: Bismuth-Containing Compounds may increase neurotoxic effects of Bismuth Subcitrate. Risk X: Avoid
Carbonic Anhydrase Inhibitors: Salicylates may increase adverse/toxic effects of Carbonic Anhydrase Inhibitors. Salicylate toxicity might be enhanced by this same combination. Management: Avoid these combinations when possible.Dichlorphenamide use with high-dose aspirin as contraindicated. If another combination is used, monitor patients closely for adverse effects. Tachypnea, anorexia, lethargy, and coma have been reported. Risk D: Consider Therapy Modification
Corticosteroids (Systemic): Salicylates may increase adverse/toxic effects of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Risk C: Monitor
Dexketoprofen: Salicylates may increase adverse/toxic effects of Dexketoprofen. Dexketoprofen may decrease therapeutic effects of Salicylates. Salicylates may decrease serum concentration of Dexketoprofen. Management: The use of high-dose salicylates (3 g/day or more in adults) together with dexketoprofen is inadvisable. Consider administering dexketoprofen 30-120 min after or at least 8 hrs before cardioprotective doses of aspirin to minimize any possible interaction. Risk X: Avoid
Ginkgo Biloba: May increase anticoagulant effects of Salicylates. Management: Consider alternatives to this combination of agents. Monitor for signs and symptoms of bleeding (especially intracranial bleeding) if salicylates are used in combination with ginkgo biloba. Risk D: Consider Therapy Modification
Hyaluronidase: Salicylates may decrease therapeutic effects of Hyaluronidase. Risk C: Monitor
Influenza Virus Vaccine (Live/Attenuated): May increase adverse/toxic effects of Salicylates. Specifically, Reye's syndrome may develop. Risk X: Avoid
Loop Diuretics: Salicylates may decrease therapeutic effects of Loop Diuretics. Loop Diuretics may increase serum concentration of Salicylates. Risk C: Monitor
Methotrexate: Salicylates may increase serum concentration of Methotrexate. Salicylate doses used for prophylaxis of cardiovascular events are not likely to be of concern. Management: Consider avoiding coadministration of methotrexate and salicylates. If coadministration cannot be avoided, monitor for increased toxic effects of methotrexate. Salicylate doses used for prophylaxis of cardiovascular events are not likely to be of concern. Risk D: Consider Therapy Modification
Nonsteroidal Anti-Inflammatory Agents (Nonselective): May increase adverse/toxic effects of Salicylates. An increased risk of bleeding may be associated with use of this combination. Risk X: Avoid
Nonsteroidal Anti-Inflammatory Agents (Topical): May increase adverse/toxic effects of Salicylates. Specifically, the risk of gastrointestinal (GI) toxicity is increased. Management: Coadministration of salicylates and topical NSAIDs is not recommended. If salicylates and topical NSAIDs are coadministered, ensure the benefits outweigh the risks and monitor for increased NSAID toxicities. Risk D: Consider Therapy Modification
Potassium Phosphate: May increase serum concentration of Salicylates. Risk C: Monitor
PRALAtrexate: Salicylates may increase serum concentration of PRALAtrexate. Salicylate doses used for prophylaxis of cardiovascular events are unlikely to be of concern. Management: Consider avoiding concomitant use of salicylates and pralatrexate. If coadministered, monitor for increased pralatrexate adverse effects. Salicylate doses used for prophylaxis of cardiovascular events are not likely to be of concern. Risk D: Consider Therapy Modification
Probenecid: Salicylates may decrease therapeutic effects of Probenecid. Salicylates may increase serum concentration of Probenecid. Probenecid may increase serum concentration of Salicylates. Risk X: Avoid
Salicylates: May increase anticoagulant effects of Salicylates. Risk C: Monitor
Sulfinpyrazone: Salicylates may decrease serum concentration of Sulfinpyrazone. Risk X: Avoid
Tetracyclines: Bismuth Subsalicylate may decrease serum concentration of Tetracyclines. Management: Consider dosing tetracyclines 2 hours before or 6 hours after bismuth. The need to separate doses during Helicobacter pylori eradication regimens is questionable. Risk D: Consider Therapy Modification
Valproic Acid and Derivatives: Salicylates may increase serum concentration of Valproic Acid and Derivatives. Risk C: Monitor
Varicella Virus-Containing Vaccines: Salicylates may increase adverse/toxic effects of Varicella Virus-Containing Vaccines. Specifically, the risk for Reye's syndrome may increase. Risk X: Avoid
Bismuth subsalicylate is converted to bismuth and salicylic acid in the GI tract. Following oral administration, salicylates cross the placenta. Very little bismuth is systemically absorbed from this preparation (Bierer 1990; Lione 1988).
Following ingestion of bismuth subsalicylate, plasma salicylate concentrations may be comparable to those following ingestion of aspirin (Bierer 1990; Lione 1988). Refer to the aspirin monograph for additional information related to salicylates and pregnancy.
Bismuth subsalicylate should not be used in pregnant patients for the treatment of dyspepsia or acute diarrhea (Body 2016) and current guidelines do not recommend use for the treatment or prevention of travelers' diarrhea in pregnancy (CDC 2020).
Salicylates enter breast milk (Bar-Oz 2003). Following ingestion of bismuth subsalicylate, plasma salicylate concentrations may be comparable to those following ingestion of aspirin (Bierer 1990). Refer to the aspirin monograph for additional information related to salicylates and breastfeeding.
It is not known if bismuth is present in breast milk; however, absorption is limited following oral administration of this preparation at usual doses (Bierer 1990).
A case report describes bowel obstruction in a breastfed infant whose mother applied a bismuth-containing ointment to her nipples prior to breastfeeding (Ingestion of bismuth-containing 1974).
Drink plenty of fluids to help prevent dehydration caused by diarrhea. Some products may contain phenylalanine, potassium, and/or sodium.
Bismuth subsalicylate exhibits both antisecretory and antimicrobial action. This agent may provide some anti-inflammatory action as well. The salicylate moiety provides antisecretory effect and the bismuth exhibits antimicrobial directly against bacterial and viral gastrointestinal pathogens.
Absorption: Bismuth: <1%; Subsalicylate: >80%
Distribution: Salicylate: Vd: 170 mL/kg
Protein binding, plasma: Bismuth and salicylate: >90%
Metabolism: Bismuth subsalicylate is converted to bismuth and salicylic acid in the GI tract.
Half-life elimination: Terminal: Bismuth: 21 to 72 days; Salicylate: 2 to 5 hours
Excretion: Bismuth: Urine and biliary; Salicylate: Urine (10% excreted unchanged)
