# Parkinsonism - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - 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 date: 2026-09 ## Verified against - Parkinsonism - disease-level clinical article (parkinsonism-clinical.txt) ## Treatment metadata - Referral & safety-netting (no drug therapy) - Trihexyphenidyl — oral.solid - Amantadine — 100 mg — oral.solid ## Complete treatment card ```text PARKINSONISM 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) Review status: REVIEWED against the source listed above (2026-09) 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 Source StatPearls "Parkinsonism" - disease-level clinical article Status traced to the source above Rx: Main treatment | Anticholinergic | NMDA antagonist MAIN TREATMENT 1. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult 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 Peds Children follow the same pathway: recognise and refer. Neither medicine below is a primary-care paediatric treatment. Source No dose - referral pathway, no medicine given in primary care Why 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. Caution 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 2. TRIHEXYPHENIDYL [1st line] Adult 0.5 to 1 mg twice daily, increased gradually to 2 mg three times daily - long-term Peds Not a primary-care paediatric indication; refer. 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. Caution 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. Egypt PARKINOL 5 MG 100 TABS. EL NILE. 55.00 EGP (0.55/unit) NMDA ANTAGONIST 3. AMANTADINE [2nd line] Adult 100 mg two or three times daily - long-term Peds Not a primary-care paediatric indication; refer. 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. Caution 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. Egypt 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 PHARM... 54.00 EGP (0.90/unit) PK-MERZ 100 MG 30 F.C.TABS. MARCYRL PHARM... 27.00 EGP (0.90/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)