From the Guidelines
For this 60-year-old female with Down syndrome presenting with nausea and abdominal discomfort, I recommend starting with ondansetron 4–8 mg bid or tid as needed for nausea, as per the AGA clinical practice update on management of medically refractory gastroparesis 1. Given her symptoms, it is crucial to consider the possibility of gastroparesis, and the use of ondansetron is supported by the latest guidelines. Additionally, a thorough review of her medication regimen is necessary to identify potential causes of her gastrointestinal symptoms, such as cyclobenzaprine and tamsulosin, which can cause gastrointestinal side effects. Her hypothyroidism should also be reassessed, as inadequate thyroid replacement can cause gastrointestinal symptoms 1. Some key points to consider in her management plan include:
- Basic laboratory testing, including complete blood count, comprehensive metabolic panel, thyroid function tests, and lipase to rule out common causes of abdominal discomfort
- An abdominal ultrasound to evaluate for gallbladder disease, liver abnormalities, or other structural causes of her symptoms
- Consideration of constipation as a potential cause, given her mobility limitations and Down syndrome, and the use of a gentle osmotic laxative like polyethylene glycol (MiraLAX) 17g daily
- Close follow-up within one week to evaluate treatment response and adjust the plan accordingly, taking into account her potential difficulty in communicating symptoms due to Down syndrome. It is also important to note that metoclopramide is the only FDA-approved medication for gastroparesis, but its use should be carefully considered due to potential side effects, and other agents like domperidone may be used off-label 1. Given the complexity of her condition and the need for a comprehensive approach, a multidisciplinary team involving gastroenterology, primary care, and possibly other specialties should be involved in her care to ensure the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Assessment
The patient is a 60-year-old female with Down syndrome, presenting with nausea and abdominal discomfort. She has a history of hyperlipidemia, ear infection, hypothyroidism, and osteoarthritis of the cervical spine. Her current medications include simvastatin, tamsulosin, alendronate, levothyroxine, and cyclobenzaprine.
Potential Causes of Nausea and Abdominal Discomfort
- Constipation: Given the patient's age and medical history, constipation is a possible cause of her symptoms 2.
- Gastrointestinal disorders: The patient's symptoms could be related to a gastrointestinal disorder, such as gastroparesis or dyspepsia, which can be treated with metoclopramide 3, 4.
Treatment Options
- Metoclopramide: This medication has been shown to be effective in treating nausea and vomiting, as well as gastrointestinal disorders such as gastroparesis and dyspepsia 3, 4. However, it can cause side effects such as extrapyramidal reactions, particularly in young patients or those receiving excessive doses 3, 4.
- Docusate: This medication is commonly used to treat constipation, but its effectiveness in older adults is limited, and it may not be the best option for this patient 2.
Considerations for Patient Care
- The patient's Down syndrome and medical history should be taken into account when developing a plan of care.
- The patient's inability to balance or walk should be considered when selecting a treatment option.
- The patient's allergy to Amoxil and cefzil should be noted, although this is not directly relevant to her current symptoms.
Next Steps
- Further evaluation of the patient's symptoms and medical history is needed to determine the underlying cause of her nausea and abdominal discomfort.
- A treatment plan should be developed based on the patient's individual needs and medical history, taking into account the potential benefits and risks of different medications, including metoclopramide 3, 4.