No

Antidiarrheal

In combination with an H₂-antagonist, used to treat and decrease rate of recurrence of active duodenal ulcer associated with H. pylori infection

D (tetracycline); B (metronidazole)

Pregnancy or lactation; children; significant renal/hepatic impairment; hypersensitivity to salicylates, bismuth, metronidazole, tetracycline, or any component

See individual monographs

See individual monographs

Central nervous system: Dizziness

Gastrointestinal: Nausea, diarrhea, abdominal pain, vomiting, anal discomfort, anorexia

Neuromuscular & skeletal: Paresthesia

See individual monographs; the most concerning agent with this combination in overdosage is bismuth subsalicylate due to the salicylate component Note: Each 262.4 mg tablet of bismuth subsalicylate contains an equivalent of 130 mg aspirin (150 mg/kg of aspirin is considered to be toxic; serious life-threatening toxicity occurs with >300 mg/kg).

Treatment: Gastrointestinal decontamination (activated charcoal for immediate release formulations (10 x dose of ASA in g), whole bowel irrigation for enteric coated tablets or when serially increasing ASA plasma levels indicate the presence of an intestinal bezoar), supportive and symptomatic treatment with emphasis on correcting fluid, electrolyte, blood glucose, and acid-base disturbances; elimination is enhanced with urinary alkalization (sodium bicarbonate infusion with potassium), multiple-dose activated charcoal, and hemodialysis.

See individual monographs

Bismuth subsalicylate, metronidazole, and tetracycline individually have demonstrated in vitro activity against most susceptible strains of H. pylori isolated from patients with duodenal ulcers. Resistance to metronidazole is increasing in the U.S.; an alternative regimen, not containing metronidazole, if H. pylori is not eradicated follow therapy.

No data on combination; see individual monographs

Adults: Chew 2 bismuth subsalicylate 262.4 mg tablets, swallow 1 metronidazole 250 mg tablet, and swallow 1 tetracycline 500 mg capsule plus an H₂-antagonist 4 times/day at meals and bedtime for 14 days; follow with 8 oz of water

See individual monographs

Dizziness common; metronidazole has been reported to cause depression, insomnia, confusion, panic, delusions, hallucinations, and exacerbation of schizophrenia; tetracycline has been reported to produce memory disturbances as well as mood stabilizing and antidepressant effects

Metronidazole and tetracycline may increase serum lithium levels and produce lithium toxicity; monitor serum lithium levels

No information available to require special precautions

Tetracyclines are not recommended for use during pregnancy since they can cause enamel hypoplasia and permanent teeth discoloration; long-term use associated with oral candidiasis

Drink adequate amounts of fluid, particularly with the bedtime tetracycline dose to reduce the risk of esophageal irritation and ulceration; if a dose is missed, continue the normal regimen until the medication is gone; do not take double doses; see your physician if more than 4 doses are missed or if ringing in the ears occur; avoid alcoholic beverages during therapy and for at least 1 day afterward; avoid concurrent use of oral contraceptives (use an alternative method) since tetracyclines may make birth control pills less effective; use protective clothing and avoid prolonged exposure to the sun and ultraviolet light; a temporary and harmless darkening of the tongue and a black stool may occur.

Tablet:

Bismuth subsalicylate: Chewable: 262.4 mg

Metronidazole: 250 mg

Capsule: Tetracycline: 500 mg