chronic

Parkinsonism

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources3 sources

ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class ND66 - condition scope only, no dose · Parkinson Disease - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470193/ · Parkinsonism - disease-level clinical article (parkinsonism-clinical.txt)

Verified against1 document

Parkinsonism - disease-level clinical article (parkinsonism-clinical.txt)

Verified date2026-09

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (4)

Sleep disturbances, reduced facial expression, one-sided clumsiness, and ongoing fatigue are common early complaints in Parkinson disease [fatigue]
Patients often describe limb stiffness, and a cogwheel quality to the stiffness is a hallmark feature
Speech often becomes soft, and some patients develop difficulty speaking [slurred speech]
Stress makes the tremor worse [tremor]

Signs — what you find (6)

Rigidity shows as increased resistance to passive movement, often worse on one side, with a ratchet-like cogwheel quality through the range of motion [reduced range of movement]
The classic tremor is a resting pill-rolling tremor at 4 to 5.3 Hz that rarely involves the head [tremor]
Postural instability shows as a shuffling gait with a shortened stride and a higher fall risk [festinating gait]
Vascular parkinsonism often shows early gait and balance trouble, a wide-based or shuffling gait with truncal ataxia, and pseudobulbar features like slurred speech and swallowing trouble [festinating gait · slurred speech · unsteadiness]
Drug-induced parkinsonism tends to be symmetric and widespread, which helps distinguish it from Parkinson disease, along with the timing of starting the causative drug
Toxin-induced parkinsonism raises muscle tone with cogwheel rigidity, bradykinesia, and a tendency to fall when walking backward [bradykinesia · cogwheel rigidity]

Tests (6)

No blood test or scan is required to diagnose Parkinson disease, though response to dopaminergic medication supports it
MRI is used to exclude other causes of parkinsonism such as a tumor, NPH, or stroke
DAT-ligand SPECT or PET imaging shows reduced dopamine transporter uptake, supporting the diagnosis
NPH imaging typically shows enlarged ventricles without significant brain atrophy
In drug-induced parkinsonism the DAT scan usually shows symmetric striatal uptake, unlike the asymmetric loss seen in true Parkinson disease
Genetic testing can help identify a cause in juvenile parkinsonism, particularly with a significant family history

If not this — what else fits (6)

Multiple system atrophy adds autonomic features - orthostatic hypotension, erectile dysfunction, and urinary incontinence - plus cerebellar ataxia to the parkinsonian picture
Dementia with Lewy bodies combines fluctuating cognition, visual hallucinations, and REM sleep behavior disorder with parkinsonism
Progressive supranuclear palsy is marked by vertical gaze palsy, a reduced blink rate, and early falls from postural instability
Corticobasal syndrome shows asymmetric limb dystonia and myoclonus, a useless arm, plus cortical sensory loss and early dementia
Atypical parkinsonian, or Parkinson-plus, syndromes are distinguished by a poor response to levodopa
A brain tumor can present with parkinsonian resting tremor, and many patients show this feature before any other sign of a mass lesion, so diagnosis is often delayed

SourceStatPearls "Parkinsonism" - disease-level clinical article

Presentation findings are traced to the source above.

Rx: Main treatment | Anticholinergic | NMDA antagonist

MAIN TREATMENT

REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)

1st line

Adult dose and duration

A clinical syndrome of tremor, rigidity, bradykinesia, and postural instability that can be idiopathic Parkinson's disease, drug-induced, or from another cause; the GP's key task is checking for and stopping an offending drug such as an antipsychotic or metoclopramide, and referring to neurology for diagnosis and treatment initiation. - Refer, with advice

Paediatric dose

Children follow the same pathway: recognise and refer. Neither medicine below is a primary-care paediatric treatment.

Dose source

No dose - referral pathway, no medicine given in primary care

Why

Cautions

RED FLAG - Severe dysphagia leading to aspiration pneumonia: assess urgently and refer.
Referral confirms the diagnosis and looks for the cause. Where the cause is a drug, stopping that drug comes first and often resolves the symptoms on its own; the medicines below are for what persists after that.
RED FLAG - Levodopa must not be stopped abruptly - abrupt withdrawal risks neuroleptic malignant syndrome. This is separate from recognising and stopping an offending drug such as an antipsychotic.
RED FLAG - Rapid onset or symmetrical parkinsonism suggesting a drug cause rather than idiopathic disease, early falls or cognitive decline (possible atypical parkinsonism), or swallowing difficulty.

ANTICHOLINERGIC

TRIHEXYPHENIDYL

Anticholinergic

1st line

Formoral.solid

Adult dose and duration

0.5 to 1 mg twice daily, increased gradually to 2 mg three times daily - long-term

Paediatric dose

Not a primary-care paediatric indication; refer.

Dose source

Parkinsonism - disease-level clinical article (parkinsonism-clinical.txt)

Why

The article uses anticholinergics for the tremor and rigidity of parkinsonism and specifically for the drug-induced form, naming trihexyphenidyl and benztropine.

Cautions

In drug-induced parkinsonism the first step is stopping the causative drug, which on its own resolves the symptoms. Where an antipsychotic is needed for a psychiatric illness, the article prefers an atypical one for its lower risk.
In the elderly this is the drug to be careful with: confusion and hallucinations, and the antimuscarinic effects - dry mouth, constipation, urinary retention and tachycardia - which together add up to a falls risk. Start at the bottom of the range and stop it if the patient becomes confused.
The Egyptian formulary's own parkinsonism range is higher, 6 to 10 mg daily in 3 or 4 divided doses. The dose above is the article's lower starting range. The two sources do not agree, and both are stated rather than one being chosen silently.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
PARKINOL 5 MG 100 TABS.	EL NILE.	55.00 EGP (0.55/unit)

NMDA ANTAGONIST

AMANTADINE

NMDA antagonist

2nd line

Strength100 mg

Formoral.solid

Adult dose and duration

100 mg two or three times daily - long-term

Paediatric dose

Not a primary-care paediatric indication; refer.

Dose source

Parkinsonism - disease-level clinical article (parkinsonism-clinical.txt)

Why

The article's option for drug-induced parkinsonism when anticholinergics have not worked. It blocks NMDA and acetylcholine receptors, and comes as 100 mg immediate-release tablets or capsules.

Cautions

In drug-induced parkinsonism the first step is stopping the causative drug, which on its own resolves the symptoms. Where an antipsychotic is needed for a psychiatric illness, the article prefers an atypical one for its lower risk.
Excreted by the kidney - use with caution and a lower dose in kidney impairment.
Livedo reticularis and pedal oedema are the common adverse effects.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
AMANTINE 100MG 24CAPS.	MEMPHIS	6.00 EGP (0.25/unit)
VIRAFLU 100MG 10 CAPS.	SIGMA	4.00 EGP (0.40/unit)
ADAMINE 100MG 20 CAPS.	RAMEDA	18.00 EGP (0.90/unit)
INFEX 100MG 60 F.C.TAB.	MARCYRL PHARMACEUTICAL INDUSTRIES (MPI)	54.00 EGP (0.90/unit)
PK-MERZ 100 MG 30 F.C.TABS.	MARCYRL PHARMACEUTICAL INDUSTRIES (MPI) > MERZ	27.00 EGP (0.90/unit)

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.