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Bismuth Salts for Gastrointestinal Issues: A Review of the Clinical Effectiveness and Guidelines

Last updated: November 24, 2015
Project Number: RC0720-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. What is the clinical effectiveness and safety of bismuth subsalicylate for relief of diarrhea, nausea, indigestion, heartburn, or upset stomach?
  2. What are the evidence-based guidelines for the use of bismuth for the treatment of diarrhea, nausea, indigestion, heartburn, or upset stomach?
  3. What is the clinical effectiveness and safety of bismuth as part of quadruple therapy for the eradication of H. pylori?
  4. What are the evidence-based guidelines regarding the use of bismuth for the treatment of H. pylori?

Key Message

Evidence of the effectiveness and safety of bismuth subsalicylate for the relief of diarrhea was identified in one systematic review. The systematic review findings supported the clinical efficacy of bismuth subsalicylate for this indication, however bismuth subsalicylate demonstrated less clinical effectiveness in reducing the frequency of loose stools, and the duration of diarrhea than loperamide. Bismuth subsalicylate was also associated with a higher frequency of minor adverse events and was determined to be less practical than loperamide when used for the treatment of diarrhea. No evidence-based guidelines were identified for this indication. This report identified three systematic reviews, four meta-analyses, and 24 randomized clinical trials that examined bismuth-containing quadruple therapy for the eradication of Helicobacter pylori infection. Identified evidence consistently indicated that bismuth-containing quadruple therapy was superior to standard triple therapies in the presence of Helicobacter pylori antibiotic resistance. The identified evidence also consistently indicated that moxifloxacin-based triple therapy had a lower frequency of adverse event occurrences than bismuth-containing quadruple therapy. The remainder of the identified evidence for the comparative clinical efficacy and comparative safety of bismuth-containing quadruple therapy for the eradication of Helicobacter pylori infection was mixed. Three identified guidelines recommended bismuth-containing quadruple therapy as a first- or second-line treatment option, and one of these guidelines recommended preference for bismuth-containing quadruple therapy for Helicobacter pylori eradication in the presence of significant antibiotic resistance. No evidence from Canadian populations or Canadian guidelines were identified.