What is the appropriate management for a patient with a history of Human Papillomavirus (HPV) positive result, presenting for a repeat Papanicolaou (Pap) test, complaining of chronic nausea and requesting a refill of Zofran (ondansetron), with a family history of Parkinson's disease and self-reported resting tremor?

From the Guidelines

I recommend proceeding with the repeat Pap smear as scheduled, given the patient's previous HPV positive result, which is appropriate per guidelines. For the nausea, I would provide a limited refill of ondansetron (Zofran) 4mg tablets to be taken as needed for nausea, up to twice daily, as suggested by the most recent study 1. Since the patient reports this is an occasional issue triggered by certain foods, I suggest she keep a food diary to identify and avoid specific triggers.

Nausea Management

• The patient's nausea could be related to a gastrointestinal issue or medication side effect, so further evaluation may be needed if it persists or worsens despite avoiding trigger foods.
• According to the study 1, ondansetron is an effective option for managing nausea and vomiting, with a recommended dose of 4-8 mg twice or three times a day.
• The patient should be advised to take the medication as needed, up to twice daily, and to track when the nausea occurs and what makes it better or worse to provide valuable information for further evaluation.

Parkinson's Concern

• Regarding the Parkinson's concern, while no tremor is currently observed, given her family history and subjective report of resting tremor, a referral to neurology is warranted for proper evaluation, as early diagnosis and treatment can significantly impact quality of life.
• The patient should be advised that early Parkinson's symptoms can include resting tremor, bradykinesia, rigidity, and postural instability, but a specialist evaluation is necessary for diagnosis.
• I would also recommend she track when the tremor occurs and what makes it better or worse to provide valuable information for the neurologist, as this will aid in determining the best course of action for her specific situation.

From the FDA Drug Label

INDICATIONS AND USAGE Ondansetron tablets are a 5-HT 3receptor antagonist indicated for the prevention of: nausea and vomiting associated with highly emetogenic cancer chemotherapy, including cisplatin greater than or equal to 50 mg/m 2. ( 1) nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy. ( 1) nausea and vomiting associated with radiotherapy in patients receiving either total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen. ( 1) postoperative nausea and/or vomiting. ( 1)

The patient's request for nausea medication zofran (ondansetron) is for a condition (occasional nausea) that is not directly indicated in the provided drug label 2. The label only mentions prevention of nausea and vomiting associated with cancer chemotherapy, radiotherapy, or postoperative situations. Since the patient's condition does not match these indications, no conclusion can be drawn about the use of ondansetron for this patient's specific case of nausea.

From the Research

Patient's Request for Nausea Medication

• The patient is requesting a refill of Zofran (ondansetron) for ongoing nausea issues that have been present for years, which she reports are occasional and worsened by certain foods 3.
• The patient denies vomiting, which is an important consideration when evaluating the need for antiemetic medication.

Family History of Parkinson's Disease

• The patient has a family history of Parkinson's disease and reports experiencing resting tremor, which may be a symptom of Parkinson's disease 4.
• However, no tremor was realized at the time of the patient's visit.

Evaluation for Parkinson's Disease

• The patient would like an evaluation from neurology for possible Parkinson's disease, given her family history and symptoms 4.
• According to the study, diagnosis of Parkinson's disease is based on history and examination, and may involve dopamine transporter single-photon emission computed tomography to improve accuracy when the presence of parkinsonism is uncertain.

Considerations for Antiemetic Medication in Parkinson's Disease

• Metoclopramide, an antiemetic medication, has been associated with encephalopathy in patients with Parkinson's disease 5, 6.
• The use of metoclopramide in patients with Parkinson's disease may worsen symptoms or cause adverse reactions, and alternative antiemetic medications such as ondansetron may be considered 3, 7.