# Parkinson's Disease - 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 ND66.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Parkinson Disease - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470193/ · Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (carbidopa and levodopa monograph, Dosage Regimen, Adult Dosing), with the indication from Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (rasagiline monograph, Indications and Dosage Regimen, Adult dosing) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (pramipexole monograph, Indications and Dosage Regimen, Parkinson's Disease) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (amantadine monograph, Indications and Dosage Regimen, Parkinsonism) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (trihexyphenidyl monograph, Indications and Dosage Regimen, Parkinsonism) · Movicol 13.7 g powder for oral solution (macrogol 3350) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 1025) · Parkinson Disease - disease-level clinical article (parkinsons-disease-full.txt) · VIAGRA 50 mg film-coated tablets (sildenafil) SmPC sections 4.1, 4.2 and 4.3 (eMC product 1072) - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) - Egyptian National Drug Formulary - Nervous System Disorders 2025 (carbidopa and levodopa monograph, Dosage Regimen, Adult Dosing), with the indication from Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) - Egyptian National Drug Formulary - Nervous System Disorders 2025 (rasagiline monograph, Indications and Dosage Regimen, Adult dosing) - Egyptian National Drug Formulary - Nervous System Disorders 2025 (pramipexole monograph, Indications and Dosage Regimen, Parkinson's Disease) - Egyptian National Drug Formulary - Nervous System Disorders 2025 (amantadine monograph, Indications and Dosage Regimen, Parkinsonism) - Egyptian National Drug Formulary - Nervous System Disorders 2025 (trihexyphenidyl monograph, Indications and Dosage Regimen, Parkinsonism) - Movicol 13.7 g powder for oral solution (macrogol 3350) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 1025) - Parkinson Disease - disease-level clinical article (parkinsons-disease-full.txt) - VIAGRA 50 mg film-coated tablets (sildenafil) SmPC sections 4.1, 4.2 and 4.3 (eMC product 1072) ## Treatment metadata - Recognise and refer (Referral & Advice) - Carbidopa + Levodopa — oral.solid - Rasagiline — 1 mg — oral.solid - Pramipexole — oral.solid - Amantadine — 100 mg — oral.solid - Trihexyphenidyl — 5 mg — oral.solid - Macrogol 3350 — oral.liquid - Sildenafil — 50 mg — oral.solid ## Complete treatment card ```text PARKINSON'S DISEASE Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class ND66.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Parkinson Disease - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470193/ · Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (carbidopa and levodopa monograph, Dosage Regimen, Adult Dosing), with the indication from Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease-full.txt) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (rasagiline monograph, Indications and Dosage Regimen, Adult dosing) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (pramipexole monograph, Indications and Dosage Regimen, Parkinson's Disease) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (amantadine monograph, Indications and Dosage Regimen, Parkinsonism) · Egyptian National Drug Formulary - Nervous System Disorders 2025 (trihexyphenidyl monograph, Indications and Dosage Regimen, Parkinsonism) · Movicol 13.7 g powder for oral solution (macrogol 3350) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 1025) · Parkinson Disease - disease-level clinical article (parkinsons-disease-full.txt) · VIAGRA 50 mg film-coated tablets (sildenafil) SmPC sections 4.1, 4.2 and 4.3 (eMC product 1072) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (12) - Tremor at rest, usually confined to one side, is often what brings the patient in [tremor] - It quietens for some minutes after the hand is used, then returns once attention drifts and the limb rests - Tremor can be missing altogether; the diagnosis does not depend on it [tremor] - Simple tasks take longer, walking slows, and the ability to react to danger falls away - Autonomic upset is frequent: postural blood pressure drops, constipation, swallowing difficulty, urinary retention, erectile failure [constipation · urinary retention] - These autonomic complaints often fail to shift with treatment - Low mood is very frequently part of the picture [low mood] - Dementia with substantial cognitive loss commonly appears as the illness advances - Quieter features that travel with the motor signs: constipation, drooling, mood disturbance, dream sleep disorder, absent sense of smell [constipation · drooling] - The cardinal motor features are bradykinesia, resting tremor and rigidity in various combinations, and postural instability arrives later [bradykinesia · tremor] - The pathology starts a decade or more before the diagnosis is ever made - What comes before the motor signs is loss of smell, constipation, and disturbed sleep - above all dream enactment during REM sleep [constipation · loss of smell] SIGNS - what you find (8) - At the bedside they cannot tap finger against thumb quickly, keep a rhythm tapping the foot, or walk steadily - They look stiff and cannot rise from a seat unaided - Arm swing is reduced on walking, worse on one side, matching the asymmetric onset - Passive movement brings out lead pipe or cogwheel resistance - Handwriting shrinks where slowness and stiffness combine - Advanced disease: tiny slow steps, a push topples them, turning needs several shuffles, and they freeze at a doorway or when someone walks past - Unsteady walking belongs to the later stages, not the opening ones - The motor signs being asymmetric is what separates it from the other parkinsonian syndromes TESTS (10) - No blood test and no scan can settle this diagnosis by itself - It is one of the rare diagnoses that bedside examination alone can formally establish - Exclude drugs causing extrapyramidal effects, classically the older antipsychotics; those cases lack non-motor features like absent smell - MRI narrows the field and excludes mimics like normal pressure hydrocephalus or subcortical stroke - Scanning also rules out bleeding, infarction, hydrocephalus, a mass and Wilson disease - Lumbar puncture serves to exclude normal pressure hydrocephalus - Dopamine transporter scanning shows lost uptake in the basal ganglia but reads poorly, so it is not for routine use - A clear improvement on levodopa is among the most practical ways to confirm a suggestive case - Specialist clinics quantify mentation, mood, daily function, tremor, motor findings and treatment complications with the Unified Parkinson Disease Rating Scale - Confusion with essential tremor is common in the community and delays proper treatment IF NOT THIS - what else fits (6) - Essential tremor, an action or kinetic tremor that is usually on both sides - Multiple system atrophy, flagged by early postural blood pressure drops - Dementia with Lewy bodies, with early hallucinations and marked antipsychotic sensitivity - Progressive supranuclear palsy, giving impaired vertical gaze - Normal pressure hydrocephalus, with its triad of incontinence, gait apraxia and cognitive decline - Parkinsonism caused by traditional antipsychotic medication Source StatPearls "Parkinson Disease" - disease-level clinical article Status traced to the source above Rx: Main treatment | First-line dopaminergic therapy - specialist-initiated (neurology) | MAO-B inhibitor - monotherapy in early disease, or added to levodopa for end-of-dose wearing off | Dopamine agonist - alternative first drug in younger patients, or added to levodopa | Adjunct for dyskinesia and mild motor symptoms | Anticholinergic - tremor-predominant disease in a younger patient | Osmotic laxative for the constipation that comes with the disease | PDE5 inhibitor for the erectile dysfunction that comes with the disease MAIN TREATMENT 1. RECOGNISE AND REFER (REFERRAL & ADVICE) [1st line] Adult Progressive neurodegenerative disease with bradykinesia plus tremor, rigidity, or postural instability. Diagnosis and the first dopaminergic prescription are made by neurology; recognition, referral, and continuing an established regimen are everyone else's job. The drugs neurology uses are on this card. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Progressive neurodegenerative disease with bradykinesia plus tremor, rigidity, or postural instability. Diagnosis and the first dopaminergic prescription are made by neurology; recognition, referral, and continuing an established regimen are everyone else's job. The drugs neurology uses are on this card. Caution Diagnosis and the first prescription belong to neurology. The drug rows on this card exist so that the regimen is visible to any physician who sees the patient - so a prescription can be continued, a dose recognised, and abrupt withdrawal avoided - not so that treatment is started here. Before accepting the diagnosis, exclude drug-induced parkinsonism; traditional antipsychotics in particular can produce motor features indistinguishable from Parkinson disease. A patient without a good motor response to levodopa probably does not have Parkinson disease; reconsider the diagnosis. Early psychosis and vivid visual hallucinations point to dementia with Lewy bodies, in which patients are notably sensitive to antipsychotics. Parkinson disease and essential tremor are confused often in community practice, and the misdiagnosis delays appropriate treatment and worsens outcomes. Consider normal pressure hydrocephalus when parkinsonian features come with urinary incontinence, gait apraxia and cognitive decline; MRI is key to that diagnosis. Vertical gaze paralysis on examination points to progressive supranuclear palsy rather than Parkinson disease. Early autonomic failure with pyramidal and cerebellar signs points to multiple system atrophy rather than Parkinson disease. Levodopa commonly causes gastrointestinal upset, dyskinesia, and psychosis with hallucinations. On long-term follow-up watch for impulsivity, psychosis, paranoia and excessive sleepiness, which develop in many patients. RED FLAG - Falls or freezing of gait, swallowing difficulty with aspiration risk, or new confusion or hallucinations, which may reflect a medication side-effect or coexisting dementia. FIRST-LINE DOPAMINERGIC THERAPY - SPECIALIST-INITIATED (NEUROLOGY) 2. CARBIDOPA + LEVODOPA [1st line] Adult Immediate-release tablets: 25 mg/100 mg (carbidopa/levodopa) every 8 hours to start; increase by one 25 mg/100 mg tablet every day or every other day as needed, to a maximum of 200 mg/800 mg (8 tablets) daily. Where more levodopa is needed: 25 mg/250 mg three to four times daily, increased in the same way, to a maximum of 200 mg/2000 mg (8 tablets) daily. Modified-release tablets: 50 mg/200 mg twice daily, adjusted at intervals of at least 2 to 4 days, up to 8 tablets daily divided into 3 or 4 doses. - Long-term; the dose is titrated to effect and not stopped abruptly Peds Not a paediatric prescription. The formulary does not recommend it under the age of 18, because its safety in that age group has never been established. Source Egyptian National Drug Formulary - Nervous System Disorders 2025 (carbidopa and levodopa monograph, Dosage Regimen, Adult Dosing), with the indication from Parkinson Disease - StatPearls - NCBI Bookshelf - disease-level clinical article (parkinsons-disease- full.txt) Why Carbidopa with levodopa is the mainstay of Parkinson's treatment - the article makes that combination the disease's principal drug therapy, and the Egyptian formulary opens its own Indications line with Parkinson's disease, so both documents agree before a dose is read. The dose is the formulary's, printed as it writes it, immediate-release and modified-release separately. Thirteen Egyptian products are registered, from LEVOCAR 100/25 mg at 18.75 EGP to SINEMET; the register files them under CARBIDOPA+LEVODOPA, which is the name the row uses. Neurology starts and titrates this - the row exists so a physician of any grade can see the regimen, continue it, and recognise what abrupt withdrawal does. Caution NEVER STOP ABRUPTLY. Withdrawing this drug suddenly can bring on a neuroleptic- malignant-syndrome picture: rigid muscles, fever, altered mental state, and a rising creatine phosphokinase. CONTRAINDICATED: narrow-angle glaucoma. Do not give levodopa to anyone with a past melanoma or an unexplained skin lesion, because it can set a melanoma going. Avoid it wherever adrenergic drugs are barred - severe cardiovascular disease, phaeochromocytoma, an overactive thyroid, Cushing's syndrome. Also barred in serious psychosis, and alongside non-selective or type A MAO inhibitors, which must be stopped at least two weeks beforehand. Not for every parkinsonian syndrome. The formulary advises against using carbidopa with levodopa for Huntington's chorea, or for extrapyramidal effects caused by drugs. Drug- induced parkinsonism is treated by stopping the offending drug. Side effects to warn about: stomach upset, involuntary movements, and psychosis with hallucinations. What it will and will not fix: slowness and rigidity respond better than tremor does. Each dose lasts only about 3 to 4 hours, which is why wearing-off appears with time. It is also a diagnostic test. If the motor signs do not improve well on levodopa, the diagnosis is probably not Parkinson's disease. Absorption: warn the patient that a sudden switch to a high-protein diet, a very acid stomach, or iron salts can each slow levodopa down. How long the benefit lasts: expect good symptom control for something like 3 to 6 years. Beyond that the disease moves on and often stops answering to drugs at all. Impulse control disorders - compulsive gambling, buying, eating and hypersexuality - occur with levodopa and the dopamine agonists. Ask about them at review; the patient will not volunteer it. Egypt LEVOCAR 100/25MG 10 TAB. ALFACURE PHAR... 18.75 EGP (1.88/unit) LECARDOPA 275 MG 10 TABS. EL NASR 21.50 EGP (2.15/unit) LEVOCAR 50/200MG CR 10 TAB. ALFACURE PHAR... 28.25 EGP (2.83/unit) LEVOCAR 250/25 MG 30 TAB. ALFACURE PHAR... 129.00 EGP (4.30/unit) PARKICARLEVO 250/25 MG 30 TAB. FUTURE PHARMA... 147.00 EGP (4.90/unit) SINEMET 25/250 MG 20 TABS. ORGANON > GLO... 122.00 EGP (6.10/unit) SHATOO 50/200MG 7 C.R. F.C. TABS. EGYPHAR 52.00 EGP KARINOBA 250/25 MG 20 ORAL DISINTEG. TABS. DEBEIKY > ELIXIR PHARMA 110.00 EGP MAO-B INHIBITOR - MONOTHERAPY IN EARLY DISEASE, OR ADDED TO LEVODOPA FOR END-OF-DOSE WEARING OFF 3. RASAGILINE [2nd line] Adult 1 mg once daily as monotherapy (or as adjunct therapy without levodopa). As an adjunct to levodopa: 0.5 mg once daily, increased to 1 mg daily if needed for sufficient clinical response. - Long-term Peds Not a paediatric drug. The formulary states that its safety and how well it works have never been established in children or adolescents. Source Egyptian National Drug Formulary - Nervous System Disorders 2025 (rasagiline monograph, Indications and Dosage Regimen, Adult dosing) Why The Egyptian formulary's rasagiline monograph names this exact disease in its own Indications line and prints both regimens, so one document carries the indication and the dose - the same route the aspirin row on cerebrovascular-disease took in A5 chunk 4. Five Egyptian products are registered; DOPAMINECT 1 mg is 54 EGP for 20 tablets. It is the drug a neurologist reaches for when levodopa is being delayed in a younger patient, or when 'off' time has appeared. Caution CONTRAINDICATED alongside any other MAO inhibitor - and that includes products bought without a prescription, St John's Wort among them - and with pethidine. Ask what else the patient takes, including herbal products. Formulary dose adjustments: mild hepatic impairment 0.5 mg once daily; moderate or severe hepatic impairment - avoid. Patients on a CYP1A2 inhibitor (ciprofloxacin, for example) take 0.5 mg once daily. No renal adjustment. Its indication: adults with idiopathic Parkinson's disease, either on its own without levodopa, or added to levodopa where the effect wears off before the next dose is due. Not for parkinsonism from another cause. Started by neurology. This row exists so the regimen is visible and a patient already on it is not left without it. Egypt DOPAMINECT 1 MG 20 TABS. MARCYRL PHARM... 54.00 EGP (2.70/unit) PARKINTREAT 1 MG 30 TABS. ATCO PHARMA >... 195.00 EGP (6.50/unit) DOPAMINE AGONIST - ALTERNATIVE FIRST DRUG IN YOUNGER PATIENTS, OR ADDED TO LEVODOPA 4. PRAMIPEXOLE [2nd line] Adult Titrate weekly, base strengths: week 1, 0.088 mg three times daily; week 2, 0.18 mg three times daily; week 3, 0.35 mg three times daily. Thereafter the dose may be increased by 0.54 mg (base) at weekly intervals to a maximum of 3.3 mg (base) daily. Withdraw gradually at 0.54 mg (base) per day down to 0.54 mg daily, then by 0.264 mg (base) per day. - Long-term; escalate and withdraw gradually, never abruptly Peds Not a paediatric drug. The formulary does not recommend it for children or adolescents below 18 years, because the data on safety and on efficacy are lacking. Source Egyptian National Drug Formulary - Nervous System Disorders 2025 (pramipexole monograph, Indications and Dosage Regimen, Parkinson's Disease) Why The formulary's pramipexole monograph names Parkinson's disease first in its Indications and gives the full weekly titration, so one document carries both claims. The strengths on the row are pramipexole BASE, which is how the formulary writes them and how the tablets are labelled in Egypt: 0.25 mg of the salt is 0.18 mg of base. Nine Egyptian products are registered. Note that the register spells the ingredient PRAMIPEXOL, without the final 'e' - a search on the clinical spelling still reaches it. Caution Titrate, do not start at the target. Step the dose up gradually, or the patient will meet side effects they cannot live with, and blood pressure that drops on standing. When it is added to levodopa, the levodopa dose may have to come down. Sudden onset of sleep and daytime somnolence occur with the dopamine agonists - warn about driving and machinery before the first tablet. Impulse control disorders (gambling, compulsive buying, hypersexuality, binge eating) are commoner with the dopamine agonists than with levodopa. Ask directly at every review, and ask the family. Started by neurology. This row exists so the regimen is visible and a patient already on it is not left without it. Egypt DOPAROXEN 0.125MG 10 TAB. EPCI > ROXXEN 6.50 EGP (0.65/unit) DOPAROXEN 0.25MG 10 TAB. EPCI > ROXXEN 8.00 EGP (0.80/unit) SOBOPEXOLE 0.25MG 10 TAB. MULTI-APEX > ... 8.00 EGP (0.80/unit) SOBOPEXOLE 1MG 10 TAB MULTI-APEX > ... 23.00 EGP (2.30/unit) KINSORAM 0.5 MG 30 TABS. EGPI > RAMAPH... 70.50 EGP (2.35/unit) SIFROL 0.18MG 30 TAB. BOEHRINGER IN... 150.00 EGP (5.00/unit) RAMIXOLE 1 MG 30 TAB. EVA PHARMA 159.00 EGP (5.30/unit) SIFROL 0.7MG 30 TAB. BOEHRINGER IN... 645.00 EGP (21.50/unit) ADJUNCT FOR DYSKINESIA AND MILD MOTOR SYMPTOMS 5. AMANTADINE [3rd line] Adult 100 mg once daily to start, increased to 100 mg twice daily in the second week. Further increases at intervals of not less than one week; maximum 400 mg a day, with close monitoring above 200 mg a day. Withdraw gradually - halve the dose at weekly intervals. - Long-term, but the effect fades: the formulary suggests withdrawal for 3 to 4 weeks to restore it, with other anti-Parkinson therapy continued meanwhile Peds The formulary states a paediatric dose only for influenza A (children 10-15 years, 100 mg once or twice a day), not for parkinsonism. No paediatric anti-Parkinson dose is given here. Source Egyptian National Drug Formulary - Nervous System Disorders 2025 (amantadine monograph, Indications and Dosage Regimen, Parkinsonism) Why The formulary's amantadine monograph opens its Indications with parkinsonism and with the extrapyramidal reactions that drugs cause, and prints a parkinsonism dosing block, so one document carries both claims. Six Egyptian products are registered and they are the cheapest anti-Parkinson tablets on the shelf - VIRAFLU 100 mg is 4 EGP - which matters on a chronic prescription in Cairo. Caution CONTRAINDICATED: angle-closure glaucoma that has not been treated; pregnancy; severe renal disease; and hypersensitivity. Renal dosing is explicit - CrCl above 35 mL/min 100 mg daily, CrCl 15-35 mL/min 100 mg every 2 to 3 days, and CrCl below 15 mL/min is contraindicated. Above 200 mg a day toxicity climbs, so monitor closely. Maximum 400 mg a day. Hallucinations (21%), dizziness (16%), falls (13%) and orthostatic hypotension (13%) are all above 10% in the formulary's own adverse-reaction table - a heavy load in an older patient who already falls. Withdraw gradually - halve the dose at weekly intervals - and continue or start other anti-Parkinson therapy while it is off. 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) ANTICHOLINERGIC - TREMOR-PREDOMINANT DISEASE IN A YOUNGER PATIENT 6. TRIHEXYPHENIDYL [3rd line] Adult Start low and increase gradually. Usual dose 6 to 10 mg daily, divided into 3 or 4 doses at meal times; up to 12 to 15 mg daily may be required. - Long-term; do not stop abruptly Peds Not a paediatric drug. The formulary has never established either its safety or how well it works in paediatric patients. Source Egyptian National Drug Formulary - Nervous System Disorders 2025 (trihexyphenidyl monograph, Indications and Dosage Regimen, Parkinsonism) Why The formulary's trihexyphenidyl monograph names parkinsonism in its Indications and prints a parkinsonism dosing block, so one document carries both claims. It is the oldest drug here and the least well tolerated in the elderly, which is why it sits at line 3 behind levodopa and the two newer agents. The register files it as TRIHEXYPHENIDYLE, with a final 'e' - PARKINOL 5 mg, 100 tablets for 55 EGP - and a search on the clinical spelling still reaches it. Caution ABUSE POTENTIAL - trihexyphenidyl is misused for its hallucinogenic and mood-lifting effects, so prolonged use needs watching for harm. In Egypt this is a recognised drug of misuse; prescribe it knowing that, and review repeat requests. CONTRAINDICATED in narrow-angle glaucoma and in hypersensitivity. Use with great caution or avoid in myasthenia gravis - the formulary records clinical worsening. Do not stop suddenly - parkinsonian symptoms can flare acutely when it is withdrawn without tapering. Anticholinergic load: nausea, dry mouth, dizziness, nervousness and blurred vision each affect 30% to 50% of patients in the formulary's own table, and confusion, agitation and hallucinations are commoner in the elderly and in arteriosclerosis. Caution in prostatic hypertrophy, glaucoma, and obstructive GI or urinary disease. Take at divided doses with meals - before meals reduces dry mouth, after meals reduces nausea. Egypt PARKINOL 5 MG 100 TABS. EL NILE. 55.00 EGP (0.55/unit) OSMOTIC LAXATIVE FOR THE CONSTIPATION THAT COMES WITH THE DISEASE - give alongside 7. MACROGOL 3350 [add-on - not a substitute] Adult One to three sachets a day, dissolved in water. SmPC verbatim: "Adults, adolescents and older people: 1 - 3 sachets daily in divided doses, according to individual response." and "For extended use, the dose can be adjusted down to 1 or 2 sachets daily." Preparation verbatim: "Each sachet should be dissolved in 125 ml water." Where stool has already loaded the rectum the SmPC gives a separate short regimen: "Adults, adolescents and the older people: 8 sachets daily, all of which should be consumed within a 6 hour period", for no more than three days. - Longer than for ordinary constipation, and the SmPC says so by name. Verbatim: "A course of treatment for constipation with Movicol does not normally exceed 2 weeks, although this can be repeated if required. As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in the care of patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson's Disease, or induced by regular constipating medication in particular opioids and antimuscarinics." Peds Not a paediatric prescription. SmPC verbatim: "Children (below 12 years old): Not recommended. Alternative products are available for children." Parkinson's disease is an adult diagnosis in any case. Source Movicol 13.7 g powder for oral solution (macrogol 3350) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 1025) Why Both claims come from documents that were opened, and the SmPC names the disease itself rather than just the symptom. The disease article names the drug, verbatim: "Sildenafil may be prescribed for erectile dysfunction, polyethylene glycol for constipation, modafinil for excessive daytime somnolence, and methylphenidate for persistent fatigue." and frames why it belongs on the card - "Acknowledging the nonmotor manifestations of PD is essential, as these symptoms can profoundly affect quality of life and require targeted management." The SmPC's indication is "the treatment of chronic constipation", and its own posology section singles out Parkinson's Disease as a reason for extended use. Constipation in Parkinson's is not incidental: it is one of the earliest features, and it is worsened by the antimuscarinic already on the card. MOVICOL 20 sachets is on the Egyptian register at 273 EGP, with a paediatric presentation beside it. Caution RED FLAG - never give it when the bowel may be obstructed. It is contraindicated where the gut wall is perforated or blocked, structurally or functionally, in ileus, in severe inflammatory bowel disease such as Crohn's disease or ulcerative colitis, and in toxic megacolon. A rigid abdomen with absent bowel sounds is a surgical assessment, not a laxative. It can move the timing of the other drugs. By speeding transit through the gut it can briefly cut how much of another medicine is taken up. Levodopa depends on consistent absorption, so a sudden change in motor control after starting a laxative is worth asking about. Swallowing is often already impaired in this disease. Where a thickener has to be added so the patient can drink safely, the interaction between the two needs thought. Check that the patient can manage 125 ml per sachet before prescribing it. It is high in sodium. Each dose carries 186.87 mg of sodium - that is 8.125 mmol, about 9.3% of the daily ceiling the WHO advises. Taken long term for constipation, the largest daily dose reaches roughly 28% of that ceiling. That matters for a patient on a salt- restricted diet. Stop it if fluid shifts appear. Swelling, breathlessness, mounting tiredness, dehydration or signs of a failing heart mean stopping it at once and checking the electrolytes. The sachet does not replace drinking. The water used to make it up does not count towards the patient's normal daily fluids, which have to be kept up separately. Egypt MOVICOL 20 SACHETS NORGINE LIMIT... 273.00 EGP -> ! also contains potassium chloride, sodium bicarbonate, sodium chloride PDE5 INHIBITOR FOR THE ERECTILE DYSFUNCTION THAT COMES WITH THE DISEASE - give alongside 8. SILDENAFIL [add-on - not a substitute] Adult 50 mg about an hour before sex, at most once a day. SmPC verbatim: "The recommended dose is 50 mg taken as needed approximately one hour before sexual activity. Based on efficacy and tolerability, the dose may be increased to 100 mg or decreased to 25 mg. The maximum recommended dose is 100 mg. The maximum recommended dosing frequency is once per day. If VIAGRA is taken with food, the onset of activity may be delayed compared to the fasted state." The SmPC drops the starting dose to 25 mg in severe renal impairment, in hepatic impairment such as cirrhosis, and alongside a CYP3A4 inhibitor. It also warns that "sexual stimulation is required" for it to work at all. - Taken as needed rather than as a standing dose - there is no course to finish and no titration schedule to keep to. Peds Not a paediatric prescription. SmPC verbatim: "VIAGRA is not indicated for individuals below 18 years of age." Parkinson's disease is an adult diagnosis in any case. Source VIAGRA 50 mg film-coated tablets (sildenafil) SmPC sections 4.1, 4.2 and 4.3 (eMC product 1072) Why The disease article names the drug and the symptom, verbatim: "Sildenafil may be prescribed for erectile dysfunction, polyethylene glycol for constipation, modafinil for excessive daytime somnolence, and methylphenidate for persistent fatigue." and again under its own recommendations - "Current recommendations include: Sildenafil can be used to treat erectile dysfunction." The SmPC's indication section names the same condition, verbatim: "VIAGRA is indicated in adult men with erectile dysfunction, which is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance." The boundary matters and is stated plainly: the licensed disease here is erectile dysfunction, not Parkinson's disease. The row sits on this card for the same reason the macrogol row does - the article's framing that "Acknowledging the nonmotor manifestations of PD is essential, as these symptoms can profoundly affect quality of life and require targeted management." Erectile dysfunction is one of the commonest and least raised of them. Sildenafil is inexpensive in Egypt, with 50 mg tablets on the register from about 7 EGP. Caution RED FLAG - never with nitrates. Sildenafil deepens the fall in blood pressure that nitrates cause, so it is barred with nitrates in any form, and with donors of nitric oxide such as amyl nitrite. That includes an as-required glyceryl trinitrate spray the patient may not think of as a medicine. Riociguat and other guanylate cyclase stimulators are barred for the same reason. Postural hypotension is already part of Parkinson's disease and of its drugs. If the patient is taking an alpha-blocker, get that treatment settled before adding sildenafil, and think about opening at 25 mg. A patient on levodopa who already faints on standing is the one to start at 25 mg. Contraindicated where sex itself is the risk. Drugs for erectile dysfunction, sildenafil among them, are not for men in whom sexual activity is itself unwise - unstable angina, severe heart failure, and other severe cardiovascular disease. Several conditions bar it outright. It has not been studied in, and is therefore contraindicated in, severe liver impairment, blood pressure under 90/50 mmHg, a recent stroke or heart attack, and inherited degenerative disease of the retina such as retinitis pigmentosa. It is also contraindicated after non-arteritic anterior ischaemic optic neuropathy in one eye. Hypersexuality on this card is a drug effect, not an indication. Dopamine agonists cause impulse control disorders including compulsive sexual behaviour; a man on pramipexole whose complaint is a change in sexual behaviour needs that reviewed before a PDE5 inhibitor is added. Erectile dysfunction in Parkinson's disease is frequently missed because nobody asks. It is worth raising directly at review, alongside constipation and daytime sleepiness. Egypt ECTAGOR 50 MG 4 F.C. TABS. UNIPHARMA CO.... 7.00 EGP (1.75/unit) V-GONE 50 MG 10 F.C. TAB. AMRIYA 24.00 EGP (2.40/unit) VIGORAN 50MG 4 F.C.TAB. AMOUN 10.00 EGP (2.50/unit) EZEQUEL 50 MG 4 F.C.TAB. COPAD PHARMA 18.00 EGP (4.50/unit) SILVIGO 50MG 5 F.C. TABS. MEMPHIS 24.00 EGP (4.80/unit) VIGORAMA 50 MG 4 F.C.TABS. MUP 19.20 EGP (4.80/unit) VIAGRA 50 MG 4 F.C.TABS. VIATRIS 112.00 EGP (28.00/unit) SILDEN 50 MG 4 ORODISPERSIBLE TABS. EIPICO 19.00 EGP SILDINOVA 10 MG PD. FOR SUSP. 120 ML INTERNATIONAL DRUG AGENCY (IDI) 78.75 EGP -> ? strength differs, ? different route - not oral solid ANSELAFIL 10MG/ML PWD. FOR ORAL SUSP. 120 ML EVA PHARMA 98.00 EGP -> ? strength differs, ? different route - not oral solid 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)