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Several pharmacological actions mentioned in [[Ayurveda]] revolve mainly around koshtha and its components. The actions that are specifically in relation with gut are: appetite stimulant ([[dipana]]), digestive stimulant ([[pachana]]), the digestion and propelling forward (anulomana), the action of expelling the adhered waste materials without digesting them (sramsana), doing the same function by liquifying (rechana), and by breaking the food items (bhedana).[Sha.Sa.Prathama Khanda/Chapter 4]<ref name= Shargadara> Sharangadhara. Sharangadhara Samhita. Translated from Sanskrit by K.R. Srikantha Murthy. Reprint ed. Varanasi: Chaukhambha orientalia;2016.</ref>
Several pharmacological actions mentioned in [[Ayurveda]] revolve mainly around koshtha and its components. The actions that are specifically in relation with gut are: appetite stimulant ([[dipana]]), digestive stimulant ([[pachana]]), the digestion and propelling forward (anulomana), the action of expelling the adhered waste materials without digesting them (sramsana), doing the same function by liquifying (rechana), and by breaking the food items (bhedana).[Sha.Sa.Prathama Khanda/Chapter 4]<ref name= Shargadara> Sharangadhara. Sharangadhara Samhita. Translated from Sanskrit by K.R. Srikantha Murthy. Reprint ed. Varanasi: Chaukhambha orientalia;2016.</ref>
The [[Agni]]-koshtha bipolarity plays an important role in deciding medications and modalities. Some of them have been enlisted in the following table:
{| class="wikitable"
|+ Table 1: Relation of [[agni]] and koshtha with diagnosis and management
|-
! Status of [[agni]] !! Status of koshtha !! Associated features !! Line of management
|-
| |Strong (dipta) || hard bowels (krura) || Stiffness of upper and lower back, sacral region [Cha.Sa.[[Cikitsa Sthana]] 3/172] ||unctuous enema ([[anuvasana]])
|-
| | Strong (dipta)|| hard bowels (krura) || Obstruction of flatus [Cha.Sa.[[Cikitsa Sthana]] 5/25] || Nourishing foods and drinks that are unctuous and warm in properties
|-
| | Strong (dipta)|| hard bowels (krura) || Dryness, habituated to exercise, excess of [[Vata]] [A.Hr.Sutra Sthana 18/53-55]<ref name=Hridaya/> ||Therapeutic enema or pungent rectal suppositories followed by unctuous purgation
|-
| | Weak (manda) || mildly unctuous || Abdominal pain, abdominal distension in abdominal lumps caused by [[vata]] (vatika gulma) [A.Hr.Cikitsa Sthana 14/29]<ref name=Hridaya/> ||Decoctions, powders, and tablets in medicated ghee
|-
| | Weak (manda)|| mildly unctuous || Abdominal pain, abdominal distension in abdominal lumps caused by [[kapha]] (kaphaja gulma) [Cha.Sa. [[Cikitsa Sthana]] 5/54] || Decoctions, powders, and tablets
|-
| | Weak (manda)|| mildly unctuous || Kaphaja gulma, habituated to alcohol [Cha.Sa.[[Cikitsa Sthana]] 5/60] ||Medicated alcohol preparations (arishta)
|-
| |Weak (manda) || Heavy and sluggish bowels || Kaphaja gulma, very mild pain, tendency to expel [[dosha]]s, anorexia [Cha.Sa.[[Cikitsa Sthana]] 5/49] ||Therapeutic emesis ([[Vamana]])
|-
| |Weak (manda) || hard bowels (krura) || - ||Alkali (Kshara), salt (lavana) based preparations along with ghee followed by purgation [A.Hr. Sutra Sthana 18/52-53]<ref name=Hridaya/>
|-
|}
==Current evidence and research on gut==
Several domains of research have evolved around gut and its health. However, most of the research focus on microbial flora of gut. Ayurvedic literature mentions inherent microbes (sahaja krimi) that occupy the gut but are not detrimental to the host. [Chakrapani commentary on Cha.Sa.[[Vimana Sthana]] 7/9] Gut microbiota in health and disease is a zone of intense research. Gut flora is in constant interaction with the central nervous system, respiratory system, hepatobiliary system, cardiovascular system, skeletal system, and integumentary system probably via metabolites like butyrate and propionate.<ref>Feng Q, Chen WD, Wang YD. Gut microbiota: An integral moderator in health and disease. Frontiers in Microbiology. 2018 Feb 21;9(FEB):151.</ref> Even in diseases that are apparently functional like functional gastrointestinal disorders and autism spectrum disorders, the role of gut microbiota has been identified.<ref>de Palma G, Collins SM, Bercik P. The microbiota-gut-brain axis in functional gastrointestinal disorders. Gut Microbes. 2014;5(3).</ref>
The gut flora patterns vary according to age, diet, and several other stimuli. The most conspicuous changes occur in the transmission from infancy to adulthood and from adulthood to senility. In infants (especially those who belong to developed societies), due to multiple reasons like formula feeds, caesarian births, improper antibiotic use leading to impaired gut flora composition, resulting in increased prevalence of allergic and autoimmune conditions among them. Supplementation with probiotics containing protective bacteria like Bifidobacterium longum it was found to show better colonization of gut microbes in breastfed infants at one year of age compared to infants without probiotic supplements.<ref>O’brien CE, Meier AK, Cernioglo K, Mitchell RD, Casaburi G, Frese SA, et al. Early probiotic supplementation with B. infantis in breastfed infants leads to persistent colonization at 1 year. [cited 2022 Mar 21]; Available from: https://doi.org/10.1038/s41390-020-01350-0</ref> Weaning is also a critical point in gut microbial diversification, wherein the pattern of gut microbiota changes from that of an infant to that of an adult.<ref>Meng Q, Luo Z, Cao C, Sun S, Ma Q, Li Z, et al. Weaning Alters Intestinal Gene Expression Involved in Nutrient Metabolism by Shaping Gut Microbiota in Pigs. Frontiers in Microbiology. 2020 Apr 17;11:694.</ref> Among old-age population, the gut flora pattern differentiates between healthy and non-healthy. Healthy ageing was characterized by decreasing variety of the core genera of microbes, especially bacteroides. The microbial variety also correlated with the survival rates of old adults.<ref>Wilmanski T, Diener C, Rappaport N, Patwardhan S, Wiedrick J, Lapidus J, et al. Gut microbiome pattern reflects healthy ageing and predicts survival in humans. Nature Metabolism 2021 3:2 [Internet]. 2021 Feb 18 [cited 2022 Apr 5];3(2):274–86. Available from: https://www.nature.com/articles/s42255-021-00348-0</ref>
The interactions between gut flora and herbs are also emerging areas of research. It was observed that the microbiota metabolized the components of herbs to produce metabolites that significantly influence physiology. The herbs in turn modulated the composition of gut microbiota that in turn regulated their functioning.<ref>An X, Bao Q, Di S, Zhao Y, Zhao S, Zhang H, et al. The interaction between the gut Microbiota and herbal medicines. Biomedicine & Pharmacotherapy. 2019 Oct 1;118:109252.</ref> The common Ayurvedic formulation Triphala was found to promote the growth of healthy bacteria, i.e., Bifidobacteria and Lactobacilli, and inhibit the growth of pathogenic bacteria like Escherichia coli. The active compounds in Triphala were metabolized by the gut microbiome to generate antioxidant compounds.<ref>Peterson CT, Denniston K, Chopra D. Therapeutic Uses of Triphala in Ayurvedic Medicine. Journal of Alternative and Complementary Medicine (New York, NY) [Internet]. 2017;23(8):607–14. Available from: files/1341/Peterson et al. - 2017 - Therapeutic Uses of Triphala in Ayurvedic Medicine.pdf</ref> Ginger juice taken in a concentration 1.5 g/mL, for 7 days in a dose of 500 mg/kg/day increased the diversity of intestinal flora in young healthy individuals. Reduction was observed in Prevotella-to-Bacteroides ratio and pro-inflammatory microbes, and the juice also elevated the Firmicutes-to-Bacteroids ratio, Proteobacteria (anaerobic, antioxidant) and Faecalibacterium (anti-inflammatory).<ref>Wang X, Zhang D, Jiang H, Zhang S, Pang X, Gao S, et al. Gut Microbiota Variation With Short-Term Intake of Ginger Juice on Human Health. Frontiers in Microbiology. 2021 Feb 23;11:2453.</ref> Curcumin-supplemented diet was found to dose-dependently increase the survival rate and eradicate the tumor burden (at 0.5% concentration) in colitis-induced colon cancer models of IL-10 deficient mice. This action probably attributed to the increase in gut flora diversity and prevention of age-related dysbiosis.<ref>Mcfadden RMT, Larmonier CB, Shehab KW, Midura-Kiela M, Ramalingam R, Harrison CA, et al. The Role of Curcumin in Modulating Colonic Microbiota During Colitis and Colon Cancer Prevention. Inflamm Bowel Dis [Internet]. 2015 Jul 25 [cited 2022 Apr 1];21(11):2483. Available from: /pmc/articles/PMC4615313/</ref> Bio-purificatory procedures like bowel cleansing were also found to decrease the total intestinal microbial load by 31-fold and restore it within 14 to 28 days.<ref>Jalanka J, Salonen A, Salojärvi J, Ritari J, Immonen O, Marciani L, et al. Effects of bowel cleansing on the intestinal microbiota. Gut [Internet]. 2015 Oct 1 [cited 2022 Apr 6];64(10):1562–8. Available from: https://pubmed.ncbi.nlm.nih.gov/25527456/</ref> Rectal administration of buttermilk processed with Acorus calamus, Piper longum, Cyperus rotundus, Aegle marmelos, Anethum sowa, Randia spinosa, Trachyspermum ammi and Saussurea lappa for 15 days increased the abundances of Firmicutes, Proteobacteria and Deinococcus-Thermus in obese patients. Bacteroides abundance decreased, and the ratio of Firmicutes to Bacteroides increased from day 0 and 16 and then was back to baseline by day 45.<ref>Mane S, Dixit KK, Lathwal N, Dhotre D, Kadus P, Shouche YS, et al. Rectal administration of buttermilk processed with medicinal plants alters gut microbiome in obese individuals. J Diabetes Metab Disord [Internet]. 2021 Dec 1 [cited 2022 Mar 19];20(2):1415–27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/34900793</ref>
Novel drug delivery mechanisms have also developed targeting the gut and related axes. There is emerging evidence related to skin-gut-brain axis which aims to harness the possibilities of transdermal route medicine administration to influence the gut status. Amla, Neem, Aloe and multiple other drugs have been previously studied in this respect.<ref>Beri K. Perspective: Stabilizing the Microbiome Skin-Gut-Brain Axis with Natural Plant Botanical Ingredients in Cosmetics. Cosmetics [Internet]. 2018;5(2):37. Available from: http://www.mdpi.com/2079-9284/5/2/37</ref> Prebiotic, probiotic and symbiotic foods constitute a fast-growing industry having vast implications. Their enteral administration during pregnancy, lactation, and postnatal life were found to influence the maternal and neonatal gut flora and hence improve maternal and neonatal outcomes.<ref>Sohn K, Underwood MA. Prenatal and postnatal administration of prebiotics and probiotics. Seminars in Fetal and Neonatal Medicine [Internet]. 2017;22(5):284–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1744165X17300677</ref> Ayurvedic herbs have been evaluated in various studies for their prebiotic potential. Herbs like Glycyrrhiza glabra and Triphala have been identified to promote the growth of healthy bacteria and to reduce the pathogenic ones. They also influenced different groups of bacteria. Triphala increased the relative abundance of butyrate-producing bacteria whereas G. glabra increased that of propionate-producing bacteria.<ref>Peterson CT, Sharma V, Uchitel S, Denniston K, Chopra D, Mills PJ, et al. Prebiotic Potential of Herbal Medicines Used in Digestive Health and Disease. J Altern Complement Med [Internet]. 2018 Jul 1 [cited 2022 Mar 19];24(7):656–65. Available from: https://pubmed.ncbi.nlm.nih.gov/29565634/</ref> Advances in rectal drug delivery like hollow, thermos-responsive, liquid, nanoparticle-based suppositories have opened new windows of opportunity, especially in subjects where oral, intravenous, and other drug routes are inaccessible.<ref>Purohit TJ, Hanning SM, Wu Z. Advances in rectal drug delivery systems. Pharmaceutical Development and Technology [Internet]. 2018;23(10):942–52. Available from: https://www.tandfonline.com/doi/full/10.1080/10837450.2018.1484766</ref>
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