Studies of COVID-19 Patients Treated With Oral Bismuth Subsalicylate (Pepto-Bismol)

Readily available over-the-counter (OTC) medication for symptomatic relief and appropriate oral hydration can be health saving measures of great convenience for those affected by enteric bacterial and viral infections. BSS is a non-proprietary monograph product that is available in the USA and abroad, over-the-counter (OTC). Of all OTC medications for traveller's diarrhea (TD), bismuth subsalicylate (BSS) has the greatest antimicrobial activity against pathogenic bacteria .BSS has also exhibited significant inhibition on viral invasion of host cells and viral efficacy. Both BSS and bismuth oxychloride (BiOCl, which is formed in the stomach after ingestion of BSS) at low concentration (0.004-0.13mg/mL) significantly reduced norovirus (NoV) RNA levels, suggesting an in vivo antiviral mechanism. BSS has also been shown to have antiviral activity since it inhibited replication of 4 strains of rotavirus in tissue culture cells and caused a dose-dependent reduction in the growth of several enteric viruses.

Historically, BSS has been indicated and effectively used for the treatment of TD or enteric infection, mainly when vomiting occurs. Although the safety and efficacy of BSS is well known, some of the research done with BSS resides within the industry and have not been published. We have recently completed an extensive meta-analysis using unpublished clinical studies regarding BSS safety and efficacy. Meta-analyses of randomized controlled clinical trials were performed with studies specifically designed to capture prevention of manifestation and relief of diarrhea.

• Bismuth Subsalicylate 262 milligram (mg) Oral Tablet, Chewable (Drug), also known as Pepto Bismol: Pepto bismol (bismuth subsalicylate)
• Placebo oral tablet without BSS (Other): Placebo Tablet made by P \& G to contain everything except active ingredient ( BSS)

Primary outcomes

• Measure of Daily Stool Frequency for Patients With COVID Treated With Bismuth [3 days]: Number of bowel movements recorded over the 3 day study. Baseline (BL) /day1 + Day 2 + Day 3

Secondary outcomes

• Salivary SARS-CoV2 Day 3 Status Using Reverse-transcription Loop-mediated Isothermal Amplification (RT-LAMP) [Day 3 - or 48 hours after starting BSS]: Salivary SARS-CoV2 measured daily. The final outcome is SARS-CoV2 status on day 3. Clearance of SARS-CoV2 ( a negative salivary SARS-CoV2 RT-LAMP test). or Remained SARS-CoV2+ ( a positive salivary SARS-CoV2. RT-LAMP test)

Sex: All, ages: 18 Years to 85 Years

Inclusion Criteria:

To be eligible to participate in the study, patients must meet the following criteria: Ability to provide written or remote informed consent (telephone and DocuSign) Ability to comply with study requirements, Men or women 18 to 85 years of age, inclusive Current diagnosis of an initial occurrence of non-severe, non-complicated COV+ infection as defined by:

* Presence COVID-19 in the saliva using point of care (POC) Qualitative real time - polymerase chain reaction (QRT- PCR) assay.
* Management in an outpatient (i.e., non-hospital) or inpatient setting NOT on a ventilator.
* Alert and awake
* Able to chew the study drug completely.
* Women should fulfill one of the following criteria:
* Answer in the affirmative that "they are not or could not be pregnant"
* Post-menopausal; either amenorrhea ≥12 months or follicle stimulating hormone >20 mIU/mL (milli-International units)
* Surgically sterile; hysterectomy, bilateral oophorectomy, or tubal ligation.
* Women of childbearing potential participating in heterosexual sexual relations must be willing to use adequate contraception from Screening through the 21 Day visit, per Section 10.2.

Standard of care COVID-19 treatment is acceptable.

Exclusion Criteria:

Patients with any of the following will be excluded from admission into the study:

* Existence of an intra-abdominal abscess, enteric fistula, or symptomatic bowel obstruction
* History of allergy to salicylates.
* History of short gut syndrome, active ulcer or recent history of GI bleeding or melena.
* Systemic chemotherapy for the treatment of cancer during the 60 days prior to consent or planned during the study
* Active use of remdesivir.
* vaccination for COVID within 30 days.
* Current use of drugs that control diarrhea or affect peristalsis (e.g., loperamide. Opiates can be used in hospitalized patients and with outpatients if they are prescribed to a patient), or any anticipated use during the study
* Active drug, chemical, or alcohol dependency as determined by Investigator through history or urine toxicology screen
* Enrollment in any other investigational drug or device study known to interfere with Pepto bismol (bismuth subsalicylate) within the GI tract, within 30 days prior to Randomization (Day 1) or within 5 half-lives of the last dose of the previous investigational compound, whichever is longer. Vaccines are not exclusionary as they do not interfere with the mechanism of the study drug.
* Severe acute illness unrelated to COVID-19
* Pregnant, breast-feeding, or considering becoming pregnant during the study
* Planned hospitalization or surgery during the study
* Any medical, psychiatric, social, or other circumstances that may interfere with study compliance, completion, or accurate assessment of study outcomes

Participant flow

Outcome results

• Measure of Daily Stool Frequency for Patients With COVID Treated With Bismuth (Primary), Mean, bowel movements: Open Label BSS Completed Patients 3 +/- 0.5; SOC Control Group
• Salivary SARS-CoV2 Day 3 Status Using Reverse-transcription Loop-mediated Isothermal Amplification (RT-LAMP) (Secondary), Count of participants, Participants: Open Label BSS Therapy -Completed 5; Cancelled SOC Control Group 0
• Day 3 Composite 5 Symptom Score (Post hoc), Mean, score on a scale: Open Label BSS Therapy -Completed 2.9 (0 to 7); Cancelled SOC Control Group
• Day 3 Composite 3 Symptom Score (Post hoc), Mean, score on a scale: Open Label BSS Therapy -Completed 1.4 (0 to 4); Cancelled SOC Control Group

Adverse events

Time frame: Adverse events were collected during the 3 days of the BSS study.

Other adverse events by term

Limitations and caveats: 1. Changing Standard of Care. 2. Patients, floor nurses and coordinators did not always keep track of number of pills taken. 3. For better compliance, we needed to decrease number of pills/day from 24 or 8 per day. 4. Transportation after discharge and sample collection needed to be optimized. 5. There was surprising difficulty in recruiting and maintaining patients in the trial during the first year, prior to general vaccine availability. 25 patients consented and never received drug.

• Yacyshyn MB, Collins J, Chua M, Siegwald A, Yacyshyn S, Briones-Pryor V, Yacyshyn B. Feasibility study of Bismuth Subsalicylate (BSS) as an addition to standard of care for COVID-19 therapy. Curr Ther Res Clin Exp. 2022;96:100667. doi: 10.1016/j.curtheres.2022.100667. Epub 2022 Mar 30. No abstract available. PMID 35370296
• Brum JM, Gibb RD, Ramsey DL, Balan G, Yacyshyn BR. Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Dig Dis Sci. 2021 Jul;66(7):2323-2335. doi: 10.1007/s10620-020-06509-7. Epub 2020 Aug 8. PMID 32772204

• Study Protocol and Statistical Analysis Plan (PDF, 2021-01-13)
• Informed Consent Form (PDF, 2021-01-27)

• Bruce Yacyshyn, MD, Principal investigator, Adjunct Professor Systems Physiology and Pharmacology University of Cincinnati