What are the alternatives to Pepto-Bismol (Bismuth subsalicylate) for a 10-year-old patient with diarrhea who is allergic to aspirin (acetylsalicylic acid)?

From the Guidelines

For a 10-year-old with diarrhea who has an aspirin allergy, avoid Pepto-Bismol and instead use oral rehydration solutions like Pedialyte, as they are essential to prevent dehydration, offering 1-2 ounces every 15-30 minutes, according to the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1. The patient should be given oral rehydration solutions to replace lost fluids and electrolytes.

• Oral rehydration solutions like Pedialyte are recommended for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause, as stated in the 2017 IDSA guidelines 1.
• The recommended dose for oral rehydration solutions is 50–100 mL/kg over 3–4 hours for infants and children, and 2–4 L for adolescents and adults, as outlined in the 2017 IDSA guidelines 1.
• For ongoing losses, 60–120 mL ORS for each diarrheal stool or vomiting episode can be given, up to ~500 mL/day for children <10 kg body weight, and 120–240 mL ORS for each diarrheal stool or vomiting episode, up to ~1 L/day for children >10 kg body weight, as recommended in the 2017 IDSA guidelines 1.
• Antimotility drugs like loperamide should not be given to children <18 years of age with acute diarrhea, as stated in the 2017 IDSA guidelines 1.
• Probiotics such as Culturelle Kids (one packet daily) can help restore healthy gut bacteria.
• A BRAT diet (bananas, rice, applesauce, toast) provides easily digestible foods during recovery.
• For fever or discomfort, acetaminophen (Tylenol) can be given at 10-15 mg/kg every 4-6 hours.
• Contact a healthcare provider if diarrhea persists beyond 48 hours, contains blood, or is accompanied by severe abdominal pain, high fever, or signs of dehydration like decreased urination or excessive thirst.

From the FDA Drug Label

Antidiarrheal LOPERAMIDE Solution 10ml (58670-000-10) For a 10-year-old patient with diarrhea who is allergic to aspirin, loperamide is an alternative to Pepto-Bismol.

• Key benefits: Loperamide does not contain aspirin or any salicylates, making it a suitable option for patients with aspirin allergies.
• Important consideration: Loperamide is an antidiarrheal medication that can help manage diarrhea symptoms, but it is essential to consult a healthcare professional for proper evaluation and guidance [ 2 ].

From the Research

Alternatives to Pepto-Bismol for Aspirin-Allergic Patients

For a 10-year-old patient with diarrhea who is allergic to aspirin, there are alternative treatments to Pepto-Bismol (Bismuth subsalicylate). Some options include:

• Loperamide: According to 3, loperamide is a safe and effective antidiarrheal for the treatment of acute diarrhea, with few adverse reactions reported worldwide.
• Racecadotril: As shown in 4, racecadotril and loperamide are equally effective in treating acute diarrhea in children, and racecadotril has a superior tolerability and safety profile.

Considerations for Treatment

When considering treatment options, it's essential to note that:

• Loperamide is effective in treating toddler diarrhea, regardless of plasma prostaglandin levels, as stated in 5 and 6.
• Bismuth subsalicylate, the active ingredient in Pepto-Bismol, is not a suitable option due to the patient's aspirin allergy, although it has been shown to be effective in reducing the duration of diarrhea in infants and young children, as demonstrated in 7.

Treatment Options

Based on the available evidence, the following treatment options can be considered:

• Loperamide: A safe and effective antidiarrheal for acute diarrhea, as supported by 3 and 5.
• Racecadotril: An alternative to loperamide with a superior tolerability and safety profile, as shown in 4.