Bismuth subcitrate/metronidazole

Aluminum Hydroxide Magnesium Trisilicate (Gaviscon) Aluminum Hydroxide (Amphojel, ALtemaGEL) Aluminum Hydroxide + Magnesium Carbonate (Gaviscon Extra Strength, Liquid) Antidiarrheals Bismuth Subcitrate/ Metronidazole/ Tetracycline (Pylera) Bismuth Subsalicylate (Pepto-Bismol) Diphenoxylate w/ Atropine (Lomotil, Lonox)... 

Two bismuth compounds are available bismuth subsalicylate, a nonprescription formulation containing bismuth and salicylate, and bismuth subcitrate potassium. In the USA, bismuth subcitrate is available only as a combination prescription product that also contains metronidazole and tetracycline for the treatment of H pylori. Bismuth subsalicylate undergoes rapid dissociation within the stomach, allowing absorption of salicylate. Over 99% of the bismuth appears in the stool. Although minimal (< 1%), bismuth is absorbed it is stored in many tissues and has slow renal excretion. Salicylate (like aspirin) is readily absorbed and excreted in the urine. 

Diagnosis of metronidazole resistance requires /n vitro culture. Under such circumstances, a PPI, along with a standard classical tripletherapy regime, such as colloidal bismuth subcitrate or bismuth subsalicylate, with a nitro-imidazole and either tetracycline or amoxicillin may be considered. 

Bell G, Powell K, Weil J et al (1991) Experience with omeprazole in combination with either amoxycillin or colloidal bismuth subcitrate in patients with metronidazole-resistant Helicobacter pylori. Eur J Gastroenterol Hepatol 3 923-926... 

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