Nausea and Vomiting

Last updated 31 May 2026 · General Practice / Gastroenterology

📋 Key Information Summary

📋

Nausea and vomiting are symptoms, not diagnoses — always pursue the underlying cause using a systematic age- and mechanism-based approach.
Red flags demanding urgent assessment include projectile vomiting in neonates, bilious (green) vomiting at any age, haematemesis, signs of raised intracranial pressure, and dehydration ≥5 % body-weight loss.
Vomiting in adults — categorise by acute (<7 days) versus chronic (>4 weeks), then by suspected mechanism (gastrointestinal, neurological, metabolic/endocrine, drug-induced, pregnancy).
Hypertrophic pyloric stenosis typically presents at 2–8 weeks of age with progressive non-bilious projectile vomiting; the diagnostic triad is visible peristalsis, palpable olive, and metabolic (hypochloraemic, hypokalaemic) alkalosis.
Intestinal atresia presents within the first 24–48 hours of life with bilious vomiting and abdominal distension; abdominal X-ray shows a "double-bubble" sign for duodenal atresia — this is a surgical emergency.
Acute gastroenteritis in Australia is most commonly viral (rotavirus, norovirus); management is primarily oral rehydration therapy (ORT), with ondansetron as an adjunct to facilitate oral intake in moderate-to-severe vomiting.
Gastroparesis is defined as delayed gastric emptying without mechanical obstruction; the most common cause in Australia is diabetes mellitus; diagnosis requires gastric emptying scintigraphy (4-hour egg-beater study).
Oral rehydration solution (WHO-ORS) is the first-line fluid for rehydration in acute gastroenteritis across all age groups; intravenous fluids (Normal Saline or Plasmalyte) are reserved for patients unable to tolerate oral intake or with severe dehydration.
Ondansetron (Zofran®) is the most widely used anti-emetic in Australian general practice and emergency departments; it is available as an orally disintegrating tablet (ODT), making it ideal for vomiting patients.
Diabetic gastroparesis requires optimisation of glycaemic control (HbA1c target <7 %), dietary modification (small, frequent, low-fat, low-fibre meals), and prokinetic therapy with metoclopramide or domperidone as first-line agents.
Pregnancy-related nausea and vomiting affects up to 80 % of pregnancies; hyperemesis gravidarum (0.3–3 %) requires IV rehydration, thiamine supplementation, and exclusion of molar pregnancy or other pathology.
Aboriginal and Torres Strait Islander peoples have higher rates of gastroenteritis-related hospitalisation, delayed presentation, and complications — culturally safe care, health-worker support, and community-based ORT education are essential.

Introduction & Australian Epidemiology

Nausea and vomiting are among the most common presenting complaints across all age groups in Australian general practice and emergency departments. While often self-limiting, these symptoms may signal serious underlying pathology — from life-threatening surgical emergencies in neonates to intracranial pathology or metabolic derangement in adults. A structured, mechanism-based approach is essential to avoid missed diagnoses and unnecessary investigations.

Nausea is the subjective, unpleasant sensation of an urge to vomit, mediated by the vomiting centre in the medulla oblongata. Vomiting (emesis) is the forceful retrograde expulsion of gastric contents through the mouth, coordinated by the vomiting centre receiving inputs from the chemoreceptor trigger zone (CTZ), vagal and sympathetic afferents, the vestibular system, and higher cortical centres.

Australian Burden of Disease

Acute gastroenteritis accounts for an estimated 17.2 million cases annually in Australia, with ~50,000 hospitalisations and approximately 80 deaths per year (AIHW, 2023). Rotavirus vaccination has reduced rotavirus-coded hospitalisations by over 70 % since its introduction onto the National Immunisation Program (NIP) in 2007.
Gastroparesis prevalence in the general population is estimated at 1.8–4 %, but rises to 40–50 % in patients with long-standing type 1 diabetes mellitus. Australian hospital admissions for gastroparesis have increased approximately 150 % over the past two decades, driven by rising diabetes prevalence.
Pyloric stenosis occurs in 2–5 per 1,000 live births in Australia, with a male-to-female ratio of approximately 4:1. It is more common in first-born males and is associated with macrolide antibiotic exposure in the neonatal period.
Nausea and vomiting of pregnancy (NVP) affects 50–80 % of pregnancies. Hyperemesis gravidarum (HG) complicates 0.3–3.0 % and is the most common reason for hospital admission in the first trimester.

Physiology of Emesis

The vomiting centre (nucleus tractus solitarius and adjacent reticular formation) integrates signals from four key pathways:

Chemoreceptor trigger zone (CTZ) — located on the floor of the fourth ventricle, outside the blood-brain barrier; detects circulating emetogens (drugs, metabolites, toxins). Targets: dopamine D₂, serotonin 5-HT₃, NK₁ receptors.
Vagal afferents — from the GI tract (pharynx, stomach, small bowel, hepatobiliary system); primarily serotonergic (5-HT₃) and mechanoreceptor/chemoreceptor mediated.
Vestibular system — motion sickness; histaminergic (H₁) and muscarinic (M₁) pathways.
Higher cortical centres — anticipatory, psychogenic, or conditioned vomiting.

Vomiting in Adults — Diagnostic Model

A systematic approach to vomiting in adults involves determining the acuity (acute vs chronic), identifying alarm features, and then considering the most likely mechanism based on clinical context.

Acute vs Chronic Classification

Feature	Acute Vomiting (<7 days)	Chronic/Recurrent (>4 weeks)
Common causes	Gastroenteritis, food poisoning, drug side-effect, acute abdomen, migraine, DKA	Gastroparesis, GERD, functional dyspepsia, cyclical vomiting syndrome, chronic medication effect, pregnancy, intracranial pathology
Priority	Exclude surgical abdomen, obstruction, MI, raised ICP, metabolic emergency	Exclude malignancy, gastroparesis, Addison disease, medication-related, rumination syndrome
Initial workup	FBE, UEC, LFTs, lipase, glucose, β-hCG (women of childbearing age), ECG if cardiac risk	FBE, UEC, LFTs, lipase, glucose, HbA1c, TFTs, cortisol, CT abdomen/pelvis, upper endoscopy, gastric emptying study

Red Flags — Urgent Referral Required

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Bilious (green) vomiting — suggests proximal bowel obstruction until proven otherwise
Haematemesis or melaena — upper GI bleeding
Signs of peritonism or acute abdomen
Severe headache, altered consciousness, papilloedema — raised intracranial pressure
Chest pain with vomiting — exclude acute coronary syndrome (inferior MI)
Severe dehydration: oliguria, hypotension, tachycardia, confusion
New-onset vomiting in a patient >55 years with weight loss — alarm for malignancy

Mechanism-Based Diagnostic Framework

Mechanism	Examples	Key Distinguishing Features
Gastrointestinal obstruction	Small/large bowel obstruction, pyloric stenosis, gallstone ileus, hernia	Colicky pain, distension, constipation/absolute obstipation, high-pitched tinkling bowel sounds, air-fluid levels on AXR
Infectious / inflammatory	Gastroenteritis, cholecystitis, pancreatitis, appendicitis, hepatitis	Fever, diarrhoea, localised tenderness, raised inflammatory markers
Drug-induced	Opioids, chemotherapy, antibiotics, metformin, SSRIs, digoxin, alcohol	Temporal relationship to medication initiation/dose change
Neurological	Raised ICP (tumour, haemorrhage, meningitis), vestibular neuritis, migraine, basilar artery stroke	Headache, vertigo, neurological focal signs, papilloedema, nausea often disproportionate to vomiting
Metabolic / endocrine	DKA, uraemia, Addison disease, hypercalcaemia, pregnancy	Biochemical abnormality on UEC/glucose/electrolytes, other endocrine features
Functional / motility	Gastroparesis, cyclic vomiting syndrome, functional nausea/vomiting, rumination	Chronic, recurrent, exclusion of organic pathology, Rome IV criteria

Investigations in Adults

Essential

FBE, UEC, LFTs, lipase, glucose, CRP

Baseline biochemistry to assess hydration, renal function, hepatic/biliary pathology, pancreatitis, and metabolic derangement. Available at all Australian pathology providers; MBS items 66516, 66503.

Essential

Serum β-hCG

Mandatory in all women of reproductive age presenting with nausea/vomiting. MBS item 66734.

Available

Abdominal X-ray (AXR)

Useful for bowel obstruction (air-fluid levels, dilated loops), constipation, or perforation (free air). MBS item 57713.

Available

Abdominal ultrasound

First-line imaging for biliary pathology, appendicitis, pyloric stenosis (infants). MBS item 55304.

Specialist

CT abdomen/pelvis with IV contrast

Indicated for suspected malignancy, complicated obstruction, mesenteric ischaemia, or non-diagnostic ultrasound. MBS item 56803.

Specialist

Gastric emptying scintigraphy (4-hour)

Gold standard for gastroparesis diagnosis. Retention >10 % at 4 hours is diagnostic. Available at major hospital nuclear medicine departments. MBS item 61318.

Specialist

Upper GI endoscopy (OGD)

Indicated for chronic vomiting, suspected peptic ulcer disease, malignancy, or foreign body. MBS item 30473.

Available

ECG

Consider in patients with cardiac risk factors — inferior MI can present with nausea/vomiting. MBS item 11700.

Symptomatic Anti-emetic Therapy in Adults

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Ondansetron

Zofran® · Generic available · 5-HT₃ antagonist

Adult dose 4–8 mg PO (ODT) / IV / IM every 8 hours PRN

Route Oral (including ODT), IV, IM

Duration Short course (1–5 days); reassess if ongoing need

Renal adjustment Max 8 mg/day if eGFR <30 mL/min; no adjustment for mild–moderate impairment

Key notes Constipation common; risk of QT prolongation at high IV doses; avoid in long QT syndrome

PBS status ✔ PBS General Benefit

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Metoclopramide

Maxolon® · Generic available · D₂ antagonist / prokinetic

Adult dose 10 mg PO / IV / IM TDS before meals

Route Oral, IV, IM, SC

Duration Short courses (<5 days preferred); long-term use for gastroparesis under specialist guidance

Renal adjustment Reduce dose by 50 % if eGFR <30 mL/min

Key notes Black box: Risk of extrapyramidal side effects (acute dystonia, tardive dyskinesia), especially in young women. Avoid prolonged use (>12 weeks). Avoid in Parkinson disease.

PBS status ✔ PBS General Benefit

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Prochlorperazine

Stemetil® · Generic available · D₂ antagonist (phenothiazine)

Adult dose 5–10 mg PO/IM BD–TDS; or buccal 3 mg BD

Route Oral, IM, buccal

Duration Short course (<7 days)

Renal adjustment No specific adjustment; use with caution in severe renal impairment

Key notes Effective for vestibular nausea (vertigo, labyrinthitis). EPS risk similar to metoclopramide. Avoid in elderly (sedation, hypotension, falls).

PBS status ✔ PBS General Benefit

💊

Domperidone

Motilium® · Generic available · D₂ antagonist / prokinetic (peripheral)

Adult dose 10 mg PO TDS–QDS, 15–30 min before meals and at bedtime

Route Oral only (not available IV in Australia)

Duration Up to 4 weeks; longer use for gastroparesis under specialist supervision

Renal adjustment Reduce frequency to BD if eGFR <30 mL/min

Key notes Does not cross BBB significantly → fewer EPS. TGA warning re QT prolongation; avoid in cardiac disease, hepatic impairment, or with QT-prolonging drugs.

PBS status ✔ PBS General Benefit (Authority Required for gastroparesis)

⚠️

Metoclopramide caution: Extrapyramidal side effects (acute dystonia, oculogyric crisis, tardive dyskinesia) are more common in women aged <30 years and with IV administration. Administer slowly IV (>3 minutes). Always counsel patients about risk of involuntary movements. Prescribe for the shortest duration possible.

Vomiting in Infancy

Vomiting is extremely common in infancy, with physiological gastro-oesophageal reflux (GOR) affecting up to 50 % of infants under 3 months. However, persistent or bilious vomiting in a neonate or young infant must be investigated urgently, as several surgical and metabolic emergencies present in this age group.

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Bilious (green) vomiting in a neonate is a surgical emergency until proven otherwise. Differential includes intestinal malrotation with volvulus, jejunoileal atresia, meconium ileus, and Hirschsprung disease with enterocolitis. Do not delay surgical consultation.

Approach to Vomiting in Infants

Feature	Likely Benign (GOR)	Alarm Features
Vomitus colour	White/milky (non-bilious)	Green (bilious), bloody, or "coffee-ground"
Projectile?	No — effortless regurgitation	Yes — forceful, distance projectile
Growth	Thriving, appropriate weight gain	Poor weight gain, falling percentiles
Distress	Comfortable between feeds	Persistent irritability, lethargy, abdo distension
Timing of onset	After feeds, from early weeks	Onset <24 h (atresia) or 2–8 weeks (PJS)

Hypertrophic Pyloric Stenosis (PJS)

Epidemiology

Incidence: 2–5 per 1,000 live births in Australia. Male:female ratio 4:1. Peak presentation 2–8 weeks of age. Associated with first-born males, family history, and macrolide antibiotic exposure in the neonatal period (erythromycin, azithromycin). More common in Caucasian populations.

Pathophysiology

Hypertrophy and hyperplasia of the circular muscle layer of the pylorus, leading to progressive gastric outlet obstruction. The elongated, thickened pylorus forms a palpable "olive" in the right upper quadrant.

Clinical Features

Progressive non-bilious projectile vomiting beginning at 2–6 weeks, worsening over days to weeks
Vomiting typically occurs immediately or within 30 minutes of feeding
Infant remains hungry after vomiting and wants to feed again
Visible peristalsis — wave-like movement from left to right across the upper abdomen before vomiting
Palpable olive — firm, mobile, non-tender mass in the right upper quadrant or epigastrium, best palpated post-vomiting when the stomach is empty (sensitivity ~60–80 % in experienced hands)
Dehydration, weight loss, and hypochloraemic hypokalaemic metabolic alkalosis in advanced cases

Diagnosis

Essential

Pyloric ultrasound

Investigation of choice. Diagnostic criteria: pyloric muscle thickness ≥3 mm and pyloric channel length ≥14 mm. Sensitivity and specificity >95 %. MBS item 55304. Readily available in paediatric and general ultrasound departments across Australia.

Essential

Serum electrolytes (UEC)

Assess for metabolic alkalosis (elevated bicarbonate, low chloride, low potassium). Severity of alkalosis reflects chronicity and degree of dehydration.

Available

Blood gas (venous or arterial)

Confirms metabolic alkalosis and allows assessment of pH and compensation. Useful when electrolytes are ambiguous.

⚠️

Correct metabolic alkalosis before surgery. Rehydrate with 0.9 % Normal Saline + KCl (20–40 mmol/L). Pyloromyotomy should not be performed until serum chloride is ≥95 mmol/L and potassium is ≥3.0 mmol/L, as failure to correct alkalosis increases the risk of post-operative apnoea.

Management

Fluid Resuscitation

IV 0.9 % Normal Saline bolus 10–20 mL/kg over 1 hour if clinically dehydrated, then maintenance + deficit replacement. Add KCl 20–40 mmol/L once urine output established. Aim to correct chloride and potassium pre-operatively.

Nasogastric Decompression

Insert NG tube on free drainage to decompress the stomach and reduce aspiration risk. Allow small, clear-fluid feeds 4–6 hours pre-operatively.

Surgical — Ramstedt Pyloromyotomy

Definitive treatment. Traditionally open (right upper quadrant transverse incision), now commonly performed laparoscopically. Both approaches have >95 % success rate and <1 % complication rate at experienced centres. All Australian paediatric surgical centres offer this procedure.

Post-operative Feeds

Commence oral feeds 4–6 hours post-operatively. Start with small, frequent boluses of expressed breast milk or formula (e.g., 15–30 mL every 2–3 hours) and increase volumes gradually. Some post-operative vomiting is expected and usually resolves within 48 hours.

Intestinal Atresia

Intestinal atresia refers to congenital absence of a segment of the intestinal lumen, presenting in the first 24–48 hours of life with bilious vomiting and abdominal distension. It occurs in approximately 1 in 1,500–5,000 live births.

Types

Type	Location	Presentation	Imaging
Duodenal atresia	Second part of duodenum (most common)	Bilious vomiting within hours of birth; polyhydramnios antenatally; associated with Down syndrome (30 %), annular pancreas	"Double bubble" sign on AXR — dilated stomach and proximal duodenum with no gas distally
Jejunoileal atresia	Jejunum (45 %), ileum (45 %), multiple sites (10 %)	Bilious vomiting at 24–48 hours; progressive abdominal distension; failure to pass meconium	Multiple dilated loops on AXR; no "double bubble"; contrast enema shows microcolon (unused distal bowel)
Colonic atresia	Rare (5 % of intestinal atresias)	Presentation similar to jejunoileal; abdominal distension prominent	AXR: dilated loops; contrast enema: microcolon, no air in rectum

Management of Intestinal Atresia

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Intestinal atresia requires urgent surgical intervention. Transfer to a paediatric surgical centre. Initial management includes NBM, IV fluids (10 % dextrose + 0.9 % NaCl), nasogastric decompression, and broad-spectrum antibiotics (ampicillin + gentamicin ± metronidazole) to cover aspiration and peritoneal contamination if perforation is suspected.

Duodenal atresia: Duodenoduodenostomy (diamond-shaped anastomosis) — no bowel resection required
Jejunoileal atresia: Resection of atretic segment with primary anastomosis (end-to-oblique or functional end-to-end). In cases of significant length discrepancy, a Bishop-Koop or Santulli enterostomy may be required.
Colonic atresia: Resection with primary anastomosis, or staged approach (initial stoma formation) in unstable patients
Post-operative: Prolonged ileus is expected; TPN may be required until enteral feeding is tolerated. Monitor for short bowel syndrome in cases of extensive resection.

Other Important Causes of Vomiting in Infancy

Condition	Age of Onset	Key Features
Gastro-oesophageal reflux (GOR)	2 weeks – 12 months	Effortless regurgitation, thriving infant, no alarm features. Self-resolving in 90 % by 12 months.
Intestinal malrotation ± volvulus	Any age (peak: neonatal – 1 year)	Bilious vomiting, acute abdomen, shock. URGENT upper GI contrast study. Ladd procedure.
Cow's milk protein allergy (CMPA)	1–6 months	Vomiting ± bloody stools, eczema, failure to thrive. Trial of extensively hydrolysed formula or maternal elimination diet.
Inborn errors of metabolism	Neonatal period (often days 2–5)	Vomiting, lethargy, encephalopathy, metabolic acidosis. Screen with blood ammonia, lactate, amino acids, urine organic acids. Emergency metabolic referral.
Hirschsprung disease	Neonatal (failure to pass meconium in first 48 h)	Abdominal distension, bilious vomiting, delayed meconium passage. Rectal suction biopsy (absence of ganglion cells). Contrast enema: transition zone.
Raised intracranial pressure	Any age	Projectile vomiting, irritability, bulging fontanelle, sunset sign. CT/MRI brain. Urgent neurosurgical referral.

Acute Gastroenteritis

Acute gastroenteritis (AGE) is defined as diarrhoea (≥3 loose stools in 24 hours) with or without vomiting, nausea, fever, or abdominal pain, lasting <14 days. It is one of the most common reasons for emergency department attendance and hospitalisation in Australia, particularly in children under 5 years and older adults.

Australian Aetiology

Viral (most common, 60–80 %): Rotavirus (decreasing since NIP introduction), norovirus (most common in adults and outbreaks), adenovirus, astrovirus
Bacterial (10–20 %): Campylobacter (most common bacterial cause in Australia), Salmonella spp., Shigella spp., Shiga toxin-producing E. coli (STEC), Clostridioides difficile
Parasitic (5–10 %): Giardia lamblia, Cryptosporidium (associated with daycare, swimming pools, remote communities)

Assessment of Dehydration Severity

Mild

<3 % Dehydration

Thirst, slightly dry mucous membranes, normal skin turgor, normal urine output, no haemodynamic compromise.

Setting: Home / GP

Moderate

3–5 % Dehydration

Decreased skin turgor, sunken eyes, dry mucous membranes, reduced urine output, tachycardia, irritability or lethargy.

Setting: GP / ED assessment

Severe

>5 % Dehydration

Sunken fontanelle (infants), absent tears, very dry mucous membranes, marked skin tenting, oliguria/anuria, hypotension, altered consciousness, delayed capillary refill >3 seconds.

Setting: ED / Paediatric ward

Management of Acute Gastroenteritis

1. Rehydration

✅

Oral rehydration therapy (ORT) is first-line for mild-to-moderate dehydration in patients who can tolerate oral intake. WHO-ORS (osmolarity 245 mOsm/L) is preferred. Give 50–100 mL/kg over 4 hours for moderate dehydration (children), divided into small, frequent sips (5–10 mL every 2–5 minutes in vomiting children).

Mild dehydration: Continue usual feeds/ORS ad libitum; reassess in 24–48 hours
Moderate dehydration: ORS 50–100 mL/kg over 3–4 hours, then maintenance fluids + replacement of ongoing losses
Severe dehydration or inability to tolerate oral intake: IV 0.9 % Normal Saline 20 mL/kg bolus over 1–2 hours, repeat as needed. In children: Plasmalyte-148 or 0.9 % NaCl + 5 % dextrose for maintenance

2. Anti-emetics — Facilitating Oral Rehydration

💊

Ondansetron (single dose)

Zofran® ODT · 5-HT₃ antagonist

Paediatric dose <8 kg: avoid; 8–15 kg: 2 mg ODT; 15–30 kg: 4 mg ODT; >30 kg: 4–8 mg ODT — single dose only

Adult dose 4–8 mg ODT, single dose

Route Orally disintegrating tablet (ODT) — ideal for vomiting patients

Duration Single dose to facilitate ORT initiation; avoid repeated dosing for AGE

Evidence Systematic review (Freedman et al., NEJM 2006) — single-dose ondansetron ODT reduces IV rehydration rates by 50 % and hospital admission by 40 % in paediatric gastroenteritis.

PBS status ✔ PBS General Benefit

3. Dietary Management

Do NOT restrict diet — early refeeding (within 4 hours of commencing ORT) reduces illness duration and improves nutritional status
Continue breastfeeding in infants (more frequent, shorter feeds)
Avoid fruit juices, carbonated drinks, and high-sugar fluids (osmotic diarrhoea)
Age-appropriate diet: complex carbohydrates (rice, bread, potatoes), lean meats, yoghurt, fruits, and vegetables
Lactose-containing feeds may be continued — routine lactose-free formula is NOT recommended unless there is evidence of secondary lactase deficiency (protracted diarrhoea >7 days)

4. Specific Antimicrobial Therapy

⚠️

Most cases of acute gastroenteritis are self-limiting and do NOT require antibiotics. Routine use of antibiotics in uncomplicated bacterial gastroenteritis is discouraged. Reserve antibiotics for specific indications listed below.

Pathogen	Indication for Treatment	First-Line Agent	Dose (Adult)
Campylobacter spp.	Severe/protracted illness, immunocompromised, pregnancy, bacteraemia	Azithromycin	500 mg PO daily × 3 days (or 1 g day 1 then 500 mg days 2–5)
Salmonella spp. (non-typhoidal)	Bacteraemia, immunocompromised, age <3 months, prosthetic implants, severe illness	Ciprofloxacin or azithromycin	Ciprofloxacin 500 mg PO BD × 5–7 days; or azithromycin 500 mg PO daily × 3 days
Shigella spp.	All confirmed cases (reduces transmission and duration)	Azithromycin	1 g PO stat (single dose) or 500 mg PO daily × 3 days
Giardia lamblia	Confirmed diagnosis	Tinidazole (preferred) or metronidazole	Tinidazole 2 g PO single dose; or metronidazole 400 mg PO TDS × 5–7 days
Cryptosporidium	Immunocompetent: self-limiting. Immunocompromised (HIV with CD4 <200): treat.	Nitazoxanide	500 mg PO BD × 3 days (adults); not PBS-listed — Special Access Scheme
C. difficile	All confirmed cases with diarrhoea	Vancomycin (oral)	125 mg PO QDS × 10 days (first episode); fidaxomicin 200 mg PO BD × 10 days as alternative

5. When to Refer / Admit

Severe dehydration not responding to oral rehydration
Inability to tolerate any oral fluids for >6–8 hours
Bloody diarrhoea or suspected STEC/haemolytic uraemic syndrome (HUS)
Signs of peritonitis or toxic megacolon
Immunocompromised patients (HIV, transplant recipients, chemotherapy)
Infants <3 months with fever and vomiting
Significant comorbidities (chronic kidney disease, heart failure) where fluid balance is critical

Rotavirus Vaccination — Australian NIP

Rotavirus vaccine is funded on the NIP for all Australian infants:

Rotarix® (RV1): 2-dose schedule at 2 and 4 months of age (oral)
RotaTeq® (RV5): 3-dose schedule at 2, 4, and 6 months of age (oral)
First dose must be administered before 15 weeks of age; course must be completed before 8 months of age
Vaccination has reduced rotavirus-coded hospitalisations by over 70 % in Australia

Gastroparesis

Gastroparesis is a chronic disorder of gastric motility characterised by delayed gastric emptying of solids in the absence of mechanical obstruction. It significantly impairs quality of life, nutrition, and glycaemic control, and presents a substantial burden on Australian healthcare services.

Aetiology

Category	Examples	Frequency
Diabetic	Type 1 > Type 2 diabetes mellitus; chronic hyperglycaemia damages the interstitial cells of Cajal and vagal nerve function	~30–40 % of cases
Post-surgical	Fundoplication, bariatric surgery (sleeve gastrectomy, Roux-en-Y), vagotomy, lung/heart transplantation	~15–25 %
Idiopathic	No identifiable cause; may follow viral illness ("post-viral gastroparesis"); more common in young women	~30–40 %
Medication-induced	Opioids, anticholinergics, GLP-1 receptor agonists (liraglutide, semaglutide), pramlintide, calcium channel blockers	Important to exclude
Other	Systemic sclerosis, Parkinson disease, amyloidosis, hypothyroidism, chronic mesenteric ischaemia	Rare

Clinical Presentation

Cardinal symptoms: Nausea (90 %), vomiting (85 %), early satiety (60 %), postprandial fullness (75 %), bloating (75 %), upper abdominal pain (45 %)
Vomitus characteristically contains food ingested many hours previously (retained food)
In diabetic gastroparesis: erratic glycaemic control, recurrent hypoglycaemia (from mismatched insulin absorption and food delivery), and weight loss
Patients may restrict oral intake to minimise symptoms, leading to malnutrition

Diagnostic Criteria

Essential

Upper GI endoscopy (OGD)

Mandatory to exclude mechanical obstruction (stricture, tumour, bezoar, pyloric channel ulcer) before diagnosing gastroparesis. Should be performed within 12 months of diagnosis. MBS item 30473.

Essential

Gastric emptying scintigraphy (4-hour egg-beater study)

Gold standard diagnostic test. Patient ingests a radiolabelled solid meal (egg-white sandwich with ⁹⁹ᵐTc-sulphur colloid). Retention >10 % at 4 hours is diagnostic of gastroparesis. Retention >60 % at 2 hours = severe. Discontinue prokinetics and opioids 48–72 hours before testing. Available at major hospital nuclear medicine departments. MBS item 61318.

Available

SmartPill wireless motility capsule

Measures gastric emptying transit time (gastric emptying time >12 hours is abnormal). Also assesses small bowel and colonic transit. Limited availability in Australia (selected tertiary centres). Not PBS-funded.

Available

Breath test (octanoic acid breath test)

Non-invasive alternative to scintigraphy; measures ¹³CO₂ excretion after ingestion of ¹³C-octanoic acid-labelled meal. Less widely available in Australia; research tool.

Available

Antroduodenal manometry

Assesses contractility patterns; useful to differentiate myopathic vs neuropathic causes. Specialist investigation — available at select tertiary centres (Royal Adelaide, Royal Melbourne, Royal Brisbane).

Gastroparesis Severity (GCSI-based)

Mild

Mild Gastroparesis

Symptoms manageable with dietary modification. Minimal weight loss. Glycaemic control manageable. Able to maintain adequate nutrition orally.

Setting: GP — dietetic referral, outpatient

Moderate

Moderate Gastroparesis

Symptoms requiring pharmacotherapy. Moderate weight loss (5–10 %). Occasional ED presentations. Significant impact on daily function and quality of life.

Setting: GP + Gastroenterologist

Severe

Severe / Refractory Gastroparesis

Failure of medical therapy. Frequent hospitalisations. Significant malnutrition (weight loss >10 %). Requires enteral/parenteral nutrition or surgical intervention. Recurrent DKA in diabetic patients.

Setting: Tertiary Gastroenterology / Multidisciplinary

Management of Gastroparesis

1. Dietary and Lifestyle Modifications

Small, frequent meals (5–6 per day) — smaller volumes are better tolerated
Low-fat, low-fibre diet — fat delays gastric emptying; indigestible fibre (raw vegetables, legumes) may form bezoars
Well-cooked, blended, or pureed foods for severe cases
Sit upright during meals and for 1–2 hours postprandially
Avoid carbonated beverages and alcohol
Supplemental liquid nutritional supplements (e.g., Sustagen®, Ensure®) if solid intake is inadequate
Dietitian referral is recommended for all patients with confirmed gastroparesis

2. Glycaemic Optimisation (Diabetic Gastroparesis)

⚠️

Hyperglycaemia itself delays gastric emptying — acute blood glucose >15 mmol/L significantly impairs antral motility. Optimising glycaemic control (HbA1c target <7 % or individualised target) is a fundamental component of gastroparesis management. GLP-1 receptor agonists (liraglutide, semaglutide, dulaglutide) delay gastric emptying and should be ceased in patients with symptomatic gastroparesis.

3. Pharmacological Management

💊

Metoclopramide

Maxolon® · D₂ antagonist / prokinetic

Adult dose 5–10 mg PO TDS, 15–30 min before meals; SC pump 0.5–1 mg/h for refractory symptoms

Route Oral, SC, IV

Duration Trial 4–8 weeks; if no benefit, discontinue. Long-term use (>12 weeks) requires gastroenterologist oversight and documented informed consent re tardive dyskinesia risk.

Renal adjustment Halve dose if eGFR <30 mL/min

Key notes First-line prokinetic for gastroparesis per eTG. Also has anti-emetic action via CTZ. EPS risk (see warnings above). Contraindicated in Parkinson disease.

PBS status ✔ PBS General Benefit

💊

Domperidone

Motilium® · Peripheral D₂ antagonist / prokinetic

Adult dose 10 mg PO TDS–QDS, 15–30 min before meals

Route Oral

Duration Trial 4–8 weeks; reassess. Long-term use under specialist supervision.

Renal adjustment Reduce to BD if eGFR <30 mL/min

Key notes Preferred when EPS risk is a concern. Avoid with hepatic impairment, cardiac disease, QT-prolonging agents. Not available IV in Australia.

PBS status ⚠ PBS Authority Required for gastroparesis (otherwise General Benefit)

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Erythromycin

Eryc® · Generic · Motilin receptor agonist

Adult dose 40–250 mg PO TDS–QDS before meals (low-dose prokinetic regimen)

Route Oral, IV (acute flares in hospital)

Duration Effective short-term (4–8 weeks); tachyphylaxis limits long-term utility

Key notes Second-line prokinetic. Most effective in the short term. Interacts with CYP3A4 inhibitors. Use lowest effective dose to minimise GI side effects.

PBS status ✔ PBS General Benefit

💊

Ondansetron

Zofran® · 5-HT₃ antagonist (symptomatic only)

Adult dose 4–8 mg PO BD–TDS PRN for nausea/vomiting

Route Oral (ODT preferred)

Key notes Symptomatic anti-emetic — does NOT improve gastric emptying. Adjunct to prokinetic therapy. Constipation may worsen gastroparesis symptoms — use lowest effective dose.

PBS status ✔ PBS General Benefit

4. Refractory Gastroparesis — Specialist Interventions

Gastric Per-Oral Endoscopic Myotomy (G-POEM)

Emerging endoscopic technique that divides the pyloric sphincter muscle endoscopically. Symptom improvement in 50–80 % of refractory cases. Available at select Australian tertiary centres (Royal Melbourne, Prince of Wales, Royal Adelaide). Requires experienced interventional endoscopist.

Botulinum Toxin Injection (Pyloric)

Endoscopic injection of botulinum toxin (100–200 units) into the pyloric sphincter. Evidence is mixed; some centres trial it as a predictor of pyloromyotomy response. Not widely used in current Australian practice.

Gastric Electrical Stimulation (GES / Enterra®)

Implantable neurostimulator delivers high-frequency, low-energy stimulation to the gastric antrum. Indicated for refractory diabetic or idiopathic gastroparesis. Funded via Special Access Scheme or hospital funding in selected Australian centres. Improves nausea/vomiting in ~60–70 % of patients.

Enteral / Parenteral Nutrition

Jejunostomy tube (J-tube) feeding for patients unable to maintain nutrition orally. Total parenteral nutrition (TPN) as a last resort for patients with severe gastroparesis and small bowel dysmotility — central line access required, significant complication risk.

Monitoring

Regular review (every 4–8 weeks initially) to assess symptom control, weight, nutritional status, and medication tolerability
Gastroparesis Cardinal Symptom Index (GCSI) — validated symptom score for serial monitoring
HbA1c every 3 months in diabetic gastroparesis
FBE, UEC, LFTs, iron studies, vitamin B12, folate, zinc — monitor for nutritional deficiencies
Bone densitometry (DEXA) if chronic malnutrition or prolonged use of prokinetics associated with reduced oral intake
Screen for depression and anxiety — prevalence up to 50 % in gastroparesis patients

Special Populations

🤰 Pregnancy

Nausea and vomiting of pregnancy (NVP) affects 50–80 % of pregnancies; peaks at 8–12 weeks gestation; resolves by 16–20 weeks in most.

Hyperemesis gravidarum (HG): Severe NVP with ≥5 % pre-pregnancy weight loss, dehydration, ketosis, electrolyte disturbance. Occurs in 0.3–3 % of pregnancies. Requires IV rehydration (NaCl 0.9 %), thiamine (100 mg IV before glucose-containing fluids to prevent Wernicke encephalopathy), and anti-emetics.

First-line: Pyridoxine (vitamin B6) 10–25 mg PO QDS + doxycycline (avoided; use doxylamine 10–25 mg PO nocte)

Correct combination: Pyridoxine 10–25 mg PO TDS + doxylamine 10–25 mg PO nocte. Not available as a fixed combination on PBS; compounded as Restonate® or Duadox®.

Second-line: Ondansetron 4 mg PO/IV TDS

Considered safe in pregnancy (Category B1). Use after first trimester where possible; current evidence does not confirm major teratogenic risk, but a small signal for cleft palate is debated. PBS General Benefit.

Other options: Metoclopramide 10 mg PO TDS, promethazine 12.5–25 mg PO TDS, prochlorperazine 5 mg PO TDS

Exclude molar pregnancy (β-hCG, pelvic ultrasound), UTI, and other surgical causes.

Thiamine supplementation is mandatory in all patients with protracted vomiting — oral 100 mg daily (mild) or IV 100 mg TDS initially (severe HG).

👶 Paediatrics

Always assess hydration status carefully in children — use a clinical dehydration scale (e.g., WHO scale or the Clinical Dehydration Scale).

Oral rehydration therapy is first-line for mild-to-moderate dehydration. ORS can be given via syringe (small boluses of 5 mL every 1–2 minutes) in vomiting infants.

Ondansetron ODT single dose (weight-based): 8–15 kg → 2 mg; 15–30 kg → 4 mg; >30 kg → 8 mg

Single-dose ondansetron reduces IV rehydration requirements and hospital admission by 50 %. Do not use repeated doses routinely for AGE.

Avoid metoclopramide in children <1 year (increased risk of EPS); use with extreme caution in older children.

Bilious vomiting in a neonate is a surgical emergency — refer immediately to a paediatric surgical centre.

Ensure rotavirus vaccination is up to date (NIP schedule: 2 and 4 months).

👴 Elderly

Higher risk of dehydration and electrolyte disturbance — lower physiological reserve and blunted thirst response.

Common iatrogenic causes: opioids, anticholinergics, digoxin toxicity, metformin, polypharmacy.

Avoid prochlorperazine and metoclopramide where possible — increased risk of falls (sedation, hypotension) and EPS. Ondansetron is preferred.

Consider serious pathology: mesenteric ischaemia, bowel obstruction, acute coronary syndrome (inferior MI), medication toxicity.

Dehydration risk compounded by diuretics, ACE inhibitors, ARBs, NSAIDs — review medications when acute vomiting occurs.

🫘 Renal Impairment

Uraemia itself causes nausea and vomiting (elevated urea, metabolic acidosis). Consider need for renal replacement therapy.

Ondansetron: max 8 mg/day if eGFR <30 mL/min. Metoclopramide: halve dose if eGFR <30 mL/min.

Domperidone: reduce frequency to BD if eGFR <30 mL/min.

Avoid magnesium-containing antacids and laxatives in CKD (hypermagnesaemia risk).

Monitor potassium carefully with electrolyte replacement during rehydration — risk of hyperkalaemia in oliguric patients.

🫁 Hepatic Impairment

Nausea is common in chronic liver disease and acute hepatitis — multifactorial (raised intra-abdominal pressure, autonomic dysfunction, metabolic derangement).

Avoid domperidone in severe hepatic impairment (Child-Pugh C) — QT prolongation risk increased.

Metoclopramide: use with caution; half-life prolonged in cirrhosis. Start low, titrate slowly.

Prochlorperazine: avoid in severe hepatic impairment — impaired metabolism, increased sedation.

Ondansetron: no dose adjustment required for mild-moderate hepatic impairment; max 8 mg/day in severe impairment.

🛡️ Immunocompromised

Broad differential includes opportunistic infections (CMV gastritis, cryptosporidiosis, microsporidiosis), medication toxicity (chemotherapy, antiretrovirals, immunosuppressants), and post-transplant complications (graft-vs-host disease).

Chemotherapy-induced nausea and vomiting (CINV): use emetogenicity-guided protocols (e.g., MASCC/ASCO guidelines) — NK₁ receptor antagonist (aprepitant) + 5-HT₃ antagonist + dexamethasone for highly emetogenic chemotherapy.

Lower threshold for investigation — FBE, CRP, blood cultures, stool MC+S, stool PCR, and imaging early in the workup.

Consider C. difficile testing in all immunocompromised patients with diarrhoea and vomiting, even without recent antibiotics.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience a significantly higher burden of gastrointestinal illness, including acute gastroenteritis, compared to the non-Indigenous Australian population. Culturally safe, community-informed approaches are essential to improving outcomes.

Gastroenteritis burden

Acute gastroenteritis hospitalisation rates are 3–5 times higher for Aboriginal and Torres Strait Islander children compared to non-Indigenous children. Rates are highest in remote and very remote communities (AIHW, 2023). Rotavirus vaccination coverage has improved, but remains lower in some remote communities.

Environmental factors

Overcrowded housing, limited access to safe drinking water, and inadequate sanitation infrastructure in some remote communities contribute to higher rates of infectious gastroenteritis. The National Partnership on Remote Housing and Closing the Gap targets address these social determinants.

Access to healthcare

Remote communities may have limited access to medical practitioners, pathology services, and imaging. Aboriginal Health Practitioners (AHPs) and Aboriginal Community Controlled Health Organisations (ACCHOs) are the frontline of healthcare delivery. Oral rehydration therapy can be effectively delivered by trained AHPs and community health workers. Telehealth for specialist consultation (Royal Flying Doctor Service, specialist outreach) is essential.

Dehydration recognition

Community education programs on recognition of dehydration in children (sunken eyes, reduced tears, decreased urine output, lethargy) and early ORS use are critical. RHDAustralia and NACCHO resources should be utilised. Home-made ORS is not recommended — pre-packaged ORS sachets should be stocked in all remote clinics.

H. pylori prevalence

Helicobacter pylori infection prevalence is significantly higher in Aboriginal and Torres Strait Islander communities (30–70 % in some remote communities vs 15–20 % nationally). This contributes to higher rates of peptic ulcer disease, chronic gastritis, and gastric malignancy. Consider H. pylori testing in the context of chronic nausea, dyspepsia, or iron deficiency.

Cultural safety

Use culturally appropriate health education materials (available through NACCHO, RHDAustralia, and local ACCHOs). Respect gender-specific health business — some patients may prefer a male or female clinician. Allow time for family involvement in decision-making. Acknowledge the impact of historical and ongoing colonisation, racism, and systemic disadvantage on health outcomes and healthcare engagement. "Sorry Business" and cultural obligations may affect attendance — offer flexible follow-up arrangements.

Nutrition and food security

Food insecurity is prevalent in remote communities, with limited access to fresh fruit, vegetables, and culturally appropriate foods. The cost of healthy food in remote communities is up to 50 % higher than in urban areas (NT Market Basket Survey). This affects management of gastroparesis and post-gastroenteritis recovery. Social determinants of health must be addressed alongside acute medical management.

📚 References

1. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006;354(16):1698-1705. doi:10.1056/NEJMoa055119
2. Hasler WL. Gastroparesis: pathogenesis, diagnosis and management. Nat Rev Gastroenterol Hepatol. 2011;8(8):438-453. doi:10.1038/nrgastro.2011.99
3. American College of Gastroenterology. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2022;117(1):34-52. doi:10.14309/ajg.0000000000001546
4. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe. J Pediatr Gastroenterol Nutr. 2014;59(1):132-152. doi:10.1097/MPG.0000000000000375
5. Australian Institute of Health and Welfare (AIHW). Gastroenteritis — Australian Burden of Disease Study. Canberra: AIHW; 2023.
6. Bines JE, Danchin M, Glasgow N, et al. Rotavirus vaccination in Australia: review of the first 10 years. J Paediatr Child Health. 2018;54(7):721-728. doi:10.1111/jpc.14000
7. Macías-García F, Larrañaga-Domínguez I, Vázquez-Iglesias JL. G-POEM for refractory gastroparesis: a systematic review and meta-analysis. Gastrointest Endosc. 2022;95(6):1015-1026. doi:10.1016/j.gie.2022.01.028
8. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562-574. doi:10.1097/MPG.0000000000000729
9. Rollins MD, Barnhart DC. Hypertrophic pyloric stenosis. In: Holcomb GW, Murphy JP, eds. Ashcraft's Pediatric Surgery. 6th ed. Philadelphia: Elsevier; 2014:435-446.
10. Royal Australian College of General Practitioners (RACGP). Management of nausea and vomiting in general practice. East Melbourne: RACGP; 2023.
11. Dore MP, Pes GM, Bassotti G, Farina MA, Marras G, Graham DY. Risk factors for gastroparesis: a systematic review and meta-analysis. Neurogastroenterol Motil. 2023;35(2):e14487. doi:10.1111/nmo.14487
12. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: NHMRC; 2019.
13. Aboriginal and Torres Strait Islander Health Performance Framework. Measures of gastrointestinal disease. Canberra: Australian Government; 2023.
14. Stanghellini V, Chan FK, Hasler WL, et al. Gastroparesis. Gastroenterology. 2016;150(6):1287-1298. doi:10.1053/j.gastro.2016.02.014
15. National Centre for Immunisation Research and Surveillance (NCIRS). Rotavirus vaccines for Australian children — technical report. Westmead: NCIRS; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).