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<br/>As compared with oral administration, rectal administration is faster in action and higher in bioavailability. Vomiting can be prevented by rectal administration thus it prevents the loss of drug. The two third of rectum’s venous drainage is in the middle and inferior rectal vein which drains directly to systemic circulation and only one third of it goes to the hepatic portal system. Thus, two third of rectal administered drug bypasses the metabolic phase. It can be administered at home which doesn’t require inpatient setup as in intravenous administration. Many of the oral drugs can be modified for rectal administration by crushing and suspending them in water.
<br/>As compared with oral administration, rectal administration is faster in action and higher in bioavailability. Vomiting can be prevented by rectal administration thus it prevents the loss of drug. The two third of rectum’s venous drainage is in the middle and inferior rectal vein which drains directly to systemic circulation and only one third of it goes to the hepatic portal system. Thus, two third of rectal administered drug bypasses the metabolic phase. It can be administered at home which doesn’t require inpatient setup as in intravenous administration. Many of the oral drugs can be modified for rectal administration by crushing and suspending them in water.
<br/>There are many digestive tract problems where the rectal route can be selected for drug administration such as bowel obstruction, dysphagia etc. In palliative care and long-term care, it is the cheap and safe alternative to intravenous or subcutaneous delivery of medications.<ref name="ref10">www.en.wikipedia.org.Rectal administration.[Internet] 2023 [cited 2023 July 31].Available from https://en.wikipedia.org/wiki/Rectal_administration#:~:text=Rectal%20administration%2C%20colloquially%20known%20as,body's%20organs%20and%20bodily%20systems.</ref></p>
<br/>There are many digestive tract problems where the rectal route can be selected for drug administration such as bowel obstruction, dysphagia etc. In palliative care and long-term care, it is the cheap and safe alternative to intravenous or subcutaneous delivery of medications.<ref name="ref10">www.en.wikipedia.org.Rectal administration.[Internet] 2023 [cited 2023 July 31].Available from https://en.wikipedia.org/wiki/Rectal_administration#:~:text=Rectal%20administration%2C%20colloquially%20known%20as,body's%20organs%20and%20bodily%20systems.</ref></p>
== Methods of rectal route administration ==
<ol type="a" style="text-align:justify;"><li style="font-weight: bold;">Suppository – <span style="font-weight: normal;">Insertion of a solid drug into the rectum which dissolves to produce local and systemic effects.</span></li>
<li style="font-weight: bold;">micro-enema – <span style="font-weight: normal;">Less than 10 ml of liquid drug solution </span></li>
<li style="font-weight: bold;">large volume enema - <span style="font-weight: normal;">Greater in quantity so that it can expel the feces out and deliver the drug.</span></li>
<li style="font-weight: bold;">catheter – <span style="font-weight: normal;">A catheter that can safely remain in the rectum for repeated use is inserted.</span></li></ol>
Asthapana basti (therapeutic decoction enema) can be considered as large volume enema where the quantity of liquid helps in the propulsion of the contents from colon by peristalsis.
== Solutions used for enema ==
<ul style="text-align:justify;"><li>Plain water – It works simply by the mechanical expansion of colon.</li>
<li>Normal saline – normal saline does almost the same work except it prevents the loss of electrolytes and retains the fluid for long time which may soften an impaction.</li>
<li>Castile soap – It causes irritation of colon’s lining and increases the urgency to defecate.</li>
<li>Glycerol – It is a bowel mucosa irritant which induces peristalsis via hyperosmotic effect.</li>
<li>Equal parts of milk and molasses – They are heated together slightly above the body temperature. It can retain the water portion of enema in the intestine.</li>
<li>Mineral oils – These can act as lubricants and stool softener.<ref name="ref11">www.en.wikipedia.org.Enema.[Internet] 2023 .[Internet] 2023 [cited 2023 July 31].Available from https://en.wikipedia.org/wiki/Enema#Large_volume_enemas</ref></li></ul>
== Mode of absorption in rectal route ==
<p style="text-align:justify;">The rectal region is drained by rectal (hemorrhoidal) veins and lymphatic vessels. The superior rectal vein drains the upper part of the rectum, and its lower part drains by inferior and middle rectal veins. More specifically, the superior rectal vein drains into the portal vein, hence it passes through the liver before getting into the systemic circulation. In contrast, the inferior and middle rectal veins drain into the inferior vena cava and, therefore, directly into systemic circulation. Between these three rectal veins exist extensive anastomoses, which connect all three veins throughout the rectum. The rectum is also extensively drained by the lymphatic system that originates in the mucosa and submucosa. The influence of the lymphatic vessels on the absorption of drugs is not well established; however, it may contribute to the systemic absorption of highly lipophilic drugs. Lymphatic drainage also avoids the hepatic first-pass effect.<ref name="ref12">Susan Hua. Physiological and Pharmaceutical Considerations for Rectal Drug Formulations. Front Pharmacol. 2019; 10: 1196. doi: 10.3389/fphar.2019.01196. PMCID: PMC6805701, PMID: 31680970.</ref>
<br/>Depending on the physicochemical characteristics of the drug, transportation of drug molecules occurs passively via paracellular diffusion (between cells) or transcellular diffusion (through the cell). Paracellular transport is preferred for more hydrophilic molecules, ionized molecules, and high molecular weight compounds. However, by the narrow tight junction space in rectum it can be restricted. Therefore, the transcellular route is the main mechanism for drug absorption in the rectum.<ref name="ref13">Nunes R., Sarmento B., das Neves J. (2014). Formulation and delivery of anti-HIV rectal microbicides: advances and challenges. J. Control Release 28194, 278–294. 10.1016/j.jconrel.2014.09.013</ref> Transcellular diffusion is affected by many factors, but it is usually proportional to the lipid solubility of the drug. Drug molecules in the non-ionized form are much more lipophilic than the ionized form. At the relatively neutral pH of the rectum, basic drugs with an acid dissociation constant (pKa) near or above the physiologic range tend to be more readily absorbed, as they will predominantly be in their non-ionized form.
<br/>The rate of absorption depends on the property of constituents of basti (enema) too. The irritant property of adjuvants causes mild inflammation in the colon which alters the permeability of capillaries and thus enhances the absorption.<ref name="ref14">Swapnil SA, BK Ashok, Anup B Thakar et al. An experimental study to evaluate the pharmacokinetic aspect of Lekhana Basti (Emaciating/ Desiccating Medicated Enema). Anc Sci Life. 2011 Oct;31(2):38-43</ref></p>
== Importance of retention of the formulation ==
<p style="text-align:justify;">For local and systemic drug absorption the drugs need to be retained for an adequate period. The bio availability and efficacy of the drug is directly proportional to the contact time of the drug with the rectal mucosa. The drug molecules must cross the mucosal layer to reach the epithelial cells lining the rectum.</p>
== Importance of fluid volume ==
<p style="text-align:justify;">The small fluid volume may reduce the absorption of the drug as the rectum is deficient in fluid levels which may produce problem of dissolution of some drugs<ref name="ref15">Nunes R., Sarmento B., das Neves J. (2014). Formulation and delivery of anti-HIV rectal microbicides: advances and challenges. J. Control Release 28194, 278–294. 10.1016/j.jconrel.2014.09.013</ref> </p>
== Current research works ==
<ul style="text-align:justify;"><li>A comparative study on the effect of virechana (therapeutic purgation) and vaitarana basti in amavata (rheumatoid arthritis) patients concluded that vaitarana basti had given better relief in amavata than viechana.<ref name="ref16">Bhatkoti Mayank (2005): A comparative clinical study of vaitaranabasti and virechana karma in the management of amavata. Department of Kayachikitsa, IPGT&RA Jamnagar</ref></li>
<li>Yapana basti administered through drip method and putaka method have shown definite improvement in patients of kampavata (parkinsonism). The drip method has shown better improvement in general symptoms, associated symptoms, functional assessment, and signs.<ref name="ref17">Vinay Chaudary (2007): A clinical study of standardization of Yapana basti in the management of Kampavata. Department of Panchakarma, IPGT&RA Jamnagar</ref></li>
<li>Kala basti has shown better improvement in amavata (rheumatoid arthritis) when compared with virechana.<ref name="ref18">Gohil Jalpa H (2009): A comparative clinical study of Virechana karma and kala basti in management of Amavata. Department of Panchakarma, IPGT&RA Jamnagar</ref></li>
<li>Administration of Erandamuladi yapana basti in comparison with Erandabija ksheera paka in patients of katigraha have shown better improvement in signs and symptoms of basti group.<ref name="ref19"/>Damayanthie Fernando (2011): Assessment of Clinical Efficacy of ErandamuladiYapana Basti and ErandaBijaKshiraPaka in the management of Kati Graha w.s.r. to Lumbar Spondylosis. Department of Panchakarma, IPGT&RA Jamnagar</li>
<li>Clinically in patients treated with lekhana basti there was a decrease in s. cholesterol, s.low density lipoprotein and s. apolipoprotein B. There was a significant reduction in BMI, weight, body fat storage etc. It was effective to a lesser extent on lipid profile than triphala guggulu.<ref name="ref20"/>Shital G Bhagiya (2015): A Comparative Clinical Study of Lekhana Basti and Shamana Sneha (Triphaladi Taila) In the Management of Sthaulya W.S.R. To Obesity.Department Of panchakarma, GAAC, Ahmedabad.</li>
<li>A comparative study between the effect of rectal administration and oral administration of the same group of drugs (guduchi bhadramustadi) have proved the higher efficacy of rectal administration for the management of sthoulya.<ref name="ref21">Hemal Kumar V Dodiya (2013): A comparative clinical study on the effect of Guduchi-Bhadramustadi yoga administered orally and by basti in the management of sthaulya w.s.r to obesity. Department of Panchakarma, IPGT&RA Jamnagar</ref></li>
<li>In a comparative study,vaitararana basti has shown marked improvement in 45% of patients of ghridrasi. Whereas siravyadha has shown marked improvement in 55% of patients. Vaitarana basti was found more effective than siravedha in stambha (stiffness), spandana (twitching), suptata (numbness), sakthikshephanigraha (SLR) and gaurava(heaviness).<ref name="ref22">Paikrao Sumedh Narayanrao (2014): A clinical study on siravedha and vaitarana basti in the management of gridhrasi with special reference to sciatica. Department of Panchakarma, IPGT&RA Jamnagar</ref></li>
<li>Yapana basti combined with patrapinda sweda and shamana medicine has shown relatively more effectiveness in the management of majority of symptoms in cervical spondylosis than the group in which yapana basti was not administered in combination.<ref name="ref23"/> The group in which yapana basti combined has also shown prevention from recurrence and long-lasting effects.</li>
<li>Study of dashamooladi basti in the management of acute stage of amavata has revealed an overall mild improvement in 40% patients, and minor improvement was observed in remaining 60% patients. Complete remission or marked improvement was not found in any of the patient.<ref name="ref24">Anjali V Makodiya (2017): A Clinical Study on Basti Karma in The Short-Term Management of Amavata W.S. R Rheumatoid Arthtitis.Department of Panchakarma, GAAC, Ahmedabad.</ref></li>
<li>The study of lekhana basti in sthoulya has shown marked improvement in 6.66% patients. The 90.90% patients achieved moderate improvement, and 3.03% patients had mild improvement whereas no patients remain unimproved after the treatment.<ref name="ref25">Chintan J Bhatt (2018): A Clinical Study of Lekhana Basti Karma in The Management of Sthaulya (Obesity), Department of Panchakarma, JSAM, Nadiad.</ref></li>
<li>Asthapana basti with udumbara kwatha in raktatisara (ulcerative colitis) has shown complete relief from signs and symptoms in one patient, marked and moderate improvement in 7 and 9 patients respectively.<ref name="ref26">Vimixa D Patel (2018): A Clinical Study of Udumbara Kvatha Basti in the Management of Raktatisara, Department Of panchakarma, JSAM, Nadiad.</ref></li></ul>
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