Introduction
Tripotassium dicitratobismuthate is a drug used in the management of ulcer cases. The main component is bismuth. When the body's pH indicator (acid or base production indicator) is below five (more acid than base), it stimulates prostaglandin production in the body, stimulating bicarbonate (base substances) and mucus production. The bismuth complex acts as a diffusion barrier for acid in the body. It helps to treat clinical conditions like diarrhea, ulcers, syphilis, upper respiratory tract infections, and warts. It also kills Helicobacter pylori bacteria in the body. Bismuth has been used for therapeutics for more than two centuries. Various forms are used, such as bismuth subnitrate, bismuth subsalicylate, bismuth subcarbonate, and tri-potassium dicitratobismuthate.
What Are the Indications for Tripotassium Dicitratobismuthate?
1. Duodenal Ulcer: It is a type of peptic ulcer. The duodenum is the first part of the small intestine, immediately after the stomach. In the duodenum lining, these ulcers cause erosion (abraded skin continuity) or small holes.
2. Gastric Ulcers: These are also known as stomach ulcers and cause painful sores in the stomach lining. A thick layer of mucus protects the stomach. As a result, erosion of the protective layer occurs. The treatment of stomach ulcers is manageable but becomes severe without treatment.
3. Helicobacter Pylori Infection: Helicobacter pylori is a type of bacteria that causes human infection. It is the most common cause of peptic ulcers. Pylori infection affects more than half the people in the world.
What Is the Normal Dose for Tripotassium Dicitratobismuthate for Medicinal Purposes?
- In children, it is usually contraindicated.
- They are used cautiously in pregnant, breastfeeding mothers and old age. Give it two to four times daily before meals for eight weeks.
What Are the Side Effects of Tripotassium Dicitratobismuthate?
The following side effects are adverse effects that are seen at a therapeutic dose:
1. Darkening of stools.
2. Mild nausea is seen.
3. Vomiting
4. Diarrhea is frequent.
5. Constipation is seen in some patients.
6. Patients feel dizzy all the time.
What Is the Toxicity of Tripotassium Dicitratobismuthate?
When the use of tri potassium dicitratobismuthate is more than the required amount rather than giving relief for conditions, it creates severe complications in the body. In addition, a higher amount causes toxicity in the body that requires immediate correction. Otherwise, it can be fatal for the patient.
These toxicity symptoms include the following:
- Melanosis.
- Erythema in fifth-day syndrome.
- Some oral manifestations.
- Skeletal problem.
- Nephrotoxicity.
- Hepatotoxicity.
- CNS toxicity.
- Methaemoglobinaemia.
Melanosis
Melanosis is a pigmentation disorder that occurs because of the overproduction of pigment melanin. At toxic doses, the drug tripotassium dicitratobismuthate causes melanosis in the body. Melanosis is mainly seen in the vagina and gums. Melanosis is considered as least significant among all adverse reactions to tripotassium dicitratobismuthate. However, bleeding and desquamation of the vaginal tissue are also seen in severe cases. Melanosis is the formation of bismuth sulfide when drugs react in the body, and sulfur-containing compounds cause the biochemical breakdown of the drug. As a result, it causes blue-black deposits on gums. In addition, melanosis causes staining of stools.
Erythema of the Ninth-Day Syndrome
The condition appears after administration of the drug during the ninth day when used to treat syphilis. This syndrome shows an erythematous rash on the trunk, head, and extremities. These erythematous lesions are usually discrete. In addition, a papular lesion (solid raised lesion less than one centimeter in diameter) is seen. Joint pains, fever, and general malaise were also seen.
Oral Manifestations of Bismuth Toxicity
Gum discoloration, gingivitis, and ulceration are associated with tripotassium dicitratobismuthate. A characteristic bluish-black discoloration is seen. Oral lesions may occur due to nephrotoxic side effects of the bismuth compound. The patients with poor oral hygiene, the development of discoloration of the gums is more with drug therapy.
Skeletal Problems With the Toxicity of Tripotassium Dicitratobismuthate
Bismuth inclusion occurs more readily in children's bones than in adults. Deposition of bismuth appears more often after a regular toxic dose of parenteral bismuth compounds. X-ray shows evidence of residues on bone. Osteoarthropathy is a second skeletal complication seen after drug toxicity in the body. Bone samples with biopsy show high bismuth deposits in patients where bismuth salts are given in high doses for treatment. Bismuth induces skeletal problems. Hypocalcemia and low serum vitamin D levels are seen in patients with bismuth-induced bony lesions. Such deficiencies also cause problems in bone.
Nephrotoxicity
High doses or toxicity of tri-potassium dicitratobismuthate cause renal changes in long-term abuse. Conditions vary from person to person. Extensive renal necrosis is also seen in some cases.
CNS Toxicity
Central nervous system symptoms include sleeplessness, drowsiness, and mental disturbance. Seizures are also seen in a significant number. Higher imaging techniques show hyperdensities in the basal ganglia, cerebellum, and cerebral cortex. Although the hyperdensities are homogeneous and bilateral after two to three months, withdrawal of bismuth slows slow disappearance within two to three months.
Methaemoglobinaemia
It is a condition of increased methemoglobin in the blood. The symptoms like cyanosis, dyspnoea, headache, weakness, and giddiness are seen in toxicity. In addition, bismuth injections lead to brownish gum discoloration, mainly due to methemoglobinemia.
How to Diagnose Tripotassium Dicitratobismuthate Toxicity?
The diagnosis of tri-potassium dicitratobismuthate toxicity is usually based on clinical symptoms and a history of tri-potassium dicitratobismuthate use. The healthcare provider may also perform some tests to help confirm the diagnosis and assess the severity of the toxicity. These tests may include:
- Blood Tests: To check kidney and liver function and detect any abnormalities.
- Urine Tests: To assess kidney function and detect any abnormalities.
- Imaging Studies: Such as X-rays, CT (computed tomography) scans or MRI (magnetic resonance imaging), may be used to detect any organ damage.
- Biopsy: In rare cases, a biopsy may be needed to examine tissue samples for signs of tri-potassium dicitratobismuthate toxicity.
What Is the Treatment for Tripotassium Dicitratobismuthate?
The treatment of tri-potassium dicitratobismuthate involves the patient being hospitalized. Immediately a gastric lavage should be done and subsequently admitted to an intensive care unit. Hemodialysis should be done in case of metabolic acidosis, acute renal failure, sore throat, and oliguria. Sodium valproate is used for recurrent seizure attacks and CNS symptoms like confusion and drowsiness.
Conclusion
Bismuth salts are old drugs used for more than two centuries. These drugs recently regained great clinical interest in treating peptic ulcer disease. Even at regular doses, medicine has some side effects, but at higher doses, it causes toxicity. Immediate treatment is required in toxicity cases; otherwise, the condition can be fatal for patients. In children, the drug is contraindicated. Also, the drug should not be used in kidney and liver-compromised patients.
