Rectal administration

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Administering medication rectally Administering-med-rectally-2.png
Administering medication rectally
Insertion of an enema nozzle as it breaches the anal sphincter. Enema nozzle insertion into rectum.jpg
Insertion of an enema nozzle as it breaches the anal sphincter.
Glycerin (laxative) suppositories for insertion into the rectum. Glycerin suppositories.jpg
Glycerin (laxative) suppositories for insertion into the rectum.
A rectal "bulb" syringe for introducing a small amount of fluid into the rectum. Rectal bulb syringe.jpg
A rectal "bulb" syringe for introducing a small amount of fluid into the rectum.
Enema equipment for introducing a large amount of fluid into the colon via the rectum. Soapsuds Enemas.jpg
Enema equipment for introducing a large amount of fluid into the colon via the rectum.

Rectal administration (colloquially known as boofing or plugging) uses the rectum as a route of administration for medication and other fluids, which are absorbed by the rectum's blood vessels, [Note 1] and flow into the body's circulatory system, which distributes the drug to the body's organs and bodily systems. [Note 2]

Contents

Mechanism and effects

A drug that is administered rectally will in general (depending on the drug) have a faster onset, higher bioavailability, shorter peak, and shorter duration than oral administration. [1] [2] Another advantage of administering a drug rectally, is that it tends to produce less nausea compared to the oral route and prevents any amount of the drug from being lost due to emesis (vomiting). In addition, the rectal route bypasses around two-thirds of the first-pass metabolism as the rectum's venous drainage is two-thirds systemic (middle and inferior rectal vein) and one-third hepatic portal system (superior rectal vein). This means the drug will reach the circulatory system with significantly less alteration and in greater concentrations. [Note 3]

Use in medicine

In addition to pharmacological effects, rectal administration has some properties which can be advantageous for the use in medicine.
Rectal administration can allow patients to remain in the home setting when the oral route is compromised. Unlike intravenous lines, which usually need to be placed in an inpatient environment and require special formulation of sterile medications, [3] a specialized rectal catheter can be placed by a clinician, such as a hospice nurse or home health nurse, in the home. Many oral forms of medications can be crushed and suspended in water to be given via a rectal catheter.

The rectal route of administration is useful for patients with any digestive tract motility problem, such as dysphagia, ileus, or bowel obstruction, that would interfere with the progression of the medication through the tract. This often includes patients near the end of life (an estimated 1.65 million people are in hospice care in the US each year). [4] Because using the rectal route enables a rapid, safe, and lower cost alternative to administration of medications, [5] it may also facilitate the care of patients in long-term care or palliative care, or as an alternative to intravenous or subcutaneous medication delivery in other instances.

Use for the consumption of psychoactive drugs

Besides its application in medicine, rectal administration is also employed by users of psychoactive substances.
Like in the medical procedure, the psychoactive drug is inserted into the anus, where it gets absorbed by the rectum's blood vessels.
A study shows that awareness of rectal administration as a possivble route of administration varies greatly among users of different drugs. The knowledge of rectal administration is highest among groups of users of alcohol, stimulants, and opiates or opioids, where over 30% of users are aware of it. [6]
The reasons for rectal administration are largely the same as with medicinal drugs: Bypassing the first-pass effect, fast onset, and a relatively high bioavailability with some drugs. [7]
Rectal administration is sometimes thought of as a safer alternative to intravenous injection of psychoactive substances [8] , which carries a significant risk of infections and illnesses like pulmonary granulomatosis. [9]
However, rectal administration of psychoactive drugs has risks associated with it also. [6] The combination of a brief acting time (compared to oral administration) and an unpredictable absorption-rate can, particularly for new users, result in a risk of overdoses. Use of shared or non-sterile equipment can increase the risk of acquiring sexually transmitted infections. [10] Some psychoactive substances like amphetamines can induce a strong vasoconstriction in the rectal vasculature and lead to intestinal ischemia. [6]
As with illicit psychoactive drugs in general, risks connected to rectal administration stem from the often unknown purity and composition of the drugs. This leads to the user not knowing if and what substances, by-products or cutting agents are present in their drugs [11] before administering them rectally. Possible impurities or falsely marketed substances greatly increase the risk of administering illicit drugs rectally.

Methods

Rectal administration of medication may be performed with any of the following:

See also

Notes

  1. The rectum has numerous blood vessels available to absorb drugs: upwards 2/3rds of the dose bypasses first-pass metabolism through systemic distribution and the rest is taken through the liver and metabolized via the hepatic portal system .
  2. The organs and systems include, depending on if the drug is able to pass the blood–brain barrier (BBB) or not, the central nervous system (CNS), peripheral nervous system (PNS), cardiovascular system (CVS), et cetera.
  3. Other ROAs that bypass first-pass metabolism include inhalation (smoking, vaporizing, etc.), intravenous injection (IV), insufflation ("snorting"), et cetera, but the oral route does not bypass first-pass metabolism.

Related Research Articles

<span class="mw-page-title-main">Heroin</span> Opioid analgesic and recreational drug

Heroin, also known as diacetylmorphine and diamorphine among other names, is a morphinan opioid substance synthesized from the dried latex of the opium poppy; it is mainly used as a recreational drug for its euphoric effects. Heroin is used medically in several countries to relieve pain, such as during childbirth or a heart attack, as well as in opioid replacement therapy. Medical-grade diamorphine is used as a pure hydrochloride salt. Various white and brown powders sold illegally around the world as heroin are routinely diluted with cutting agents. Black tar heroin is a variable admixture of morphine derivatives—predominantly 6-MAM (6-monoacetylmorphine), which is the result of crude acetylation during clandestine production of street heroin.

<span class="mw-page-title-main">Enema</span> Injection of fluid into rectum, typically en route to the colon

An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum. The word enema can also refer to the liquid injected, as well as to a device for administering such an injection.

<span class="mw-page-title-main">Intravenous therapy</span> Medication administered into a vein

Intravenous therapy is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrients for those who cannot, or will not—due to reduced mental states or otherwise—consume food or water by mouth. It may also be used to administer medications or other medical therapy such as blood products or electrolytes to correct electrolyte imbalances. Attempts at providing intravenous therapy have been recorded as early as the 1400s, but the practice did not become widespread until the 1900s after the development of techniques for safe, effective use.

<span class="mw-page-title-main">Lorazepam</span> Benzodiazepine medication

Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting. It is also used during surgery to interfere with memory formation and to sedate those who are being mechanically ventilated. It is also used, along with other treatments, for acute coronary syndrome due to cocaine use. It can be given orally, transdermally, intravenously (IV), or intramuscularly When given by injection, onset of effects is between one and thirty minutes and effects last for up to a day.

<span class="mw-page-title-main">Route of administration</span> Path by which a drug, fluid, poison, or other substance is taken into the body

In pharmacology and toxicology, a route of administration is the way by which a drug, fluid, poison, or other substance is taken into the body.

A suppository is a dosage form used to deliver medications by insertion into a body orifice, where it dissolves or melts to exert local or systemic effects. There are three types of suppositories, each to insert into a different sections: rectal suppositories into the rectum, vaginal suppositories into the vagina, and urethral suppositories into the urethra of a male.

In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

In pharmacology, bioavailability is a subcategory of absorption and is the fraction (%) of an administered drug that reaches the systemic circulation.

<span class="mw-page-title-main">First pass effect</span> Phenomenon of drug metabolism

The first pass effect is a phenomenon of drug metabolism at a specific location in the body which leads to a reduction in the concentration of the active drug before it reaches the site of action or systemic circulation. The effect is most associated with orally administered medications, but some drugs still undergo first-pass metabolism even when delivered via an alternate route. During this metabolism, drug is lost during the process of absorption which is generally related to the liver and gut wall. The liver is the major site of first pass effect; however, it can also occur in the lungs, vasculature or other metabolically active tissues in the body. Notable drugs that experience a significant first-pass effect are buprenorphine, chlorpromazine, cimetidine, diazepam, ethanol, imipramine, insulin, lidocaine, midazolam, morphine, pethidine, propranolol, and tetrahydrocannabinol (THC). First-pass metabolism is not to be confused with Phase I metabolism, which is a separate process.

<span class="mw-page-title-main">Fecal impaction</span> Solid buildup of feces in the rectum due to chronic constipation

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

<span class="mw-page-title-main">Sucralfate</span> Chemical compound and gastrointestinal medication

Sucralfate, sold under various brand names, is a medication used to treat stomach ulcers, gastroesophageal reflux disease (GERD), radiation proctitis, and stomach inflammation and to prevent stress ulcers. Its usefulness in people infected by H. pylori is limited. It is used by mouth and rectally.

<span class="mw-page-title-main">Drug injection</span> Method of introducing a drug

Drug injection is a method of introducing a drug into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body. Intravenous therapy, a form of drug injection, is universally practiced in modernized medical care. As of 2004, there were 13.2 million people worldwide who self-administered injection drugs outside of medical supervision, of which 22% are from developed countries.

Dosage forms are pharmaceutical drug products presented in a specific form for use. They contain a mixture of active ingredients and inactive components (excipients), configured in a particular way and apportioned into a specific dose. For example, two products may both be amoxicillin, but one may come in 500 mg capsules, while another may be in 250 mg chewable tablets.

An alcohol enema, also known colloquially as butt-chugging or boofing, is the act of introducing alcohol into the rectum and colon via the anus, i.e., as an enema. This method of alcohol consumption can be dangerous and even deadly because it leads to faster intoxication than drinking since the alcohol is absorbed directly into the bloodstream and bypasses the body's ability to reject the toxin by vomiting.

<span class="mw-page-title-main">Drug</span> Substance having effect(s) on the body of an individual

A drug is any chemical substance other than a nutrient or an essential dietary ingredient, which, when administered to a living organism, produces a biological effect. Consumption of drugs can be via inhalation, injection, smoking, ingestion, absorption via a patch on the skin, suppository, or dissolution under the tongue.

End-of-life care (EOLC) is health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.

<span class="mw-page-title-main">Delorazepam</span> Benzodiazepine medication

Delorazepam, also known by the synonyms chlordesmethyldiazepam and nordiclazepam, is a drug which is a benzodiazepine and a derivative of desmethyldiazepam. It is marketed in Italy, where it is available under the trade name EN and Dadumir. Delorazepam (chlordesmethyldiazepam) is also an active metabolite of the benzodiazepine drugs diclazepam and cloxazolam. Adverse effects may include hangover type effects, drowsiness, behavioural impairments and short-term memory impairments. Similar to other benzodiazepines delorazepam has anxiolytic, skeletal muscle relaxant, hypnotic and anticonvulsant properties.

Insufflation is the act of blowing something into a body cavity. Insufflation has many medical uses, most notably as a route of administration for various drugs.

The Macy Catheter is a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. The catheter was developed to make rectal access more practical and provide a way to deliver and retain liquid formulations in the distal rectum so that health practitioners can leverage the established benefits of rectal administration. Patients often need medication when the oral route is compromised, and the Macy Catheter provides an alternative for those medications that can be prescribed per rectum. The Macy Catheter is of particular relevance during the end of life, when it can help patients to remain comfortable in their home.

Transanal irrigation is medical procedure in which water is used to evacuate feces from the rectum and descending colon via the anus.

References

  1. De Boer AG, Moolenaar F, de Leede LG, Breimer DD. (1982) "Rectal drug administration: clinical pharmacokinetic considerations." Clin Pharmacokinetics. 7(4):285–311
  2. Moolenaar F, Koning B, Huizinga T. (1979) "Biopharmaceutics of rectal administration of drugs in man. Absorption rate and bioavailability of phenobarbital and its sodium salt from rectal dosage forms." International Journal of Pharmacaceutics, 4:99–109
  3. Plumer AL. 2007. Plumer's Principles and Practices of Intravenous Therapy. Lippincott Williams & Wilkins. 753 pp.
  4. "National Hospice and Palliative Care Organization's Facts and Figures: Hospice Care in America, 2013 Edition" (PDF) Archived 2014-05-13 at the Wayback Machine
  5. A Quality Improvement Study: Use of a Rectal Medication Administration Device Intervention to manage end-stage symptoms in hospice patients when the oral route fails. Poster Presentations. 6th Annual Hospice Palliative Nurses Association Clinical Practice Forum, Pittsburgh, PA, September 15-15, 2012
  6. 1 2 3 Rivers Allen, Jessica; Bridge, William (December 2017). "Strange Routes of Administration for Substances of Abuse". American Journal of Psychiatry Residents' Journal. 12 (12). American Psychiatric Association: 7–11. doi:10.1176/appi.ajp-rj.2017.121203 . Retrieved 27 October 2024.
  7. Dodou, Kalliopi (29 August 2012). "Exploring the unconventional routes — rectal and vaginal dosage formulations". The Pharmaceutical Journal. Royal Pharmaceutical Society. Retrieved 27 October 2024.
  8. "Transitioning Routes of Administration: from snorting to injecting to eating to smoking to booty bumping". NEXT Distro. 10 August 2021. Retrieved 27 October 2024.
  9. Wurcel, Alysse G.; Merchant, Elisabeth A.; Clark, Roger P.; Stone, David R. (15 December 2015). "Emerging and Underrecognized Complications of Illicit Drug Use". Clinical Infectious Diseases. 61 (12): 1840–1849. doi:10.1093/cid/civ689 . Retrieved 27 October 2024.
  10. Fleisch, Sheryl B.; Walker, Jessica N. (1 July 2020). "Surreptitious Opioid Misuse in the General Hospital via Rectal Administration: A Case Report". Psychosomatics. 61 (4). Elsevier: 405–407. doi:10.1016/j.psym.2019.12.001 . Retrieved 27 October 2024.
  11. Peck, Yoshimi; Clough, Alan R.; Culshaw, Peter N.; Liddell, Michael J. (August 2019). "Multi-drug cocktails: Impurities in commonly used illicit drugs seized by police in Queensland, Australia". Drug and Alcohol Dependence. 201. Elsevier: 49–57. doi:10.1016/j.drugalcdep.2019.03.019. ISSN   0376-8716 . Retrieved 28 October 2024.
  12. "high enema". Medical Dictionary. Merriam-Webster. Retrieved 2021-04-18.
  13. Rhodora Cruz. "Types of Enemas". Fundamentals of Nursing Practice. Professional Education, Testing and Certification Organization International. Retrieved 2021-04-18.