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Nausea and Vomiting in Palliative Care

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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  • Nausea and vomiting affect 40–70% of patients with advanced cancer and up to 60% of those receiving palliative care for non-malignant conditions in Australia.
  • A cause-based approach is essential — identify and treat reversible causes (constipation, medications, metabolic, raised ICP, gastric stasis, bowel obstruction) before escalating antiemetics.
  • Opioid-induced nausea affects 30–40% of patients commencing opioids; tolerance usually develops within 5–7 days but may require antiemetic cover during initiation.
  • Metoclopramide (dopamine antagonist / prokinetic) is first-line for gastric stasis and opioid-induced nausea; maximum 40 mg/day to avoid extrapyramidal side effects.
  • Haloperidol (low-dose, 0.5–1.5 mg) is first-line for chemical / metabolic nausea (uraemia, hypercalcaemia, hepatic failure) and drug-induced nausea.
  • Ondansetron (5-HT₃ antagonist) is reserved for chemotherapy- or radiotherapy-induced nausea and refractory nausea when other agents fail.
  • Dexamethasone (4–8 mg daily) is useful for raised intracranial pressure, hepatomegaly, and as an adjuvant in bowel obstruction.
  • Cyclizine (antihistamine) is first-line for vestibular / motion-related nausea and is commonly used in bowel obstruction in Australia.
  • In inoperable malignant bowel obstruction, a combination of cyclizine + octreotide (or hyoscine butylbromide) is the standard palliative regimen to reduce secretions and vomiting.
  • Subcutaneous (SC) is the preferred alternative route when oral intake is unreliable; continuous subcutaneous infusion (CSCI) via syringe driver is the standard delivery method in Australian palliative care.
  • Always review and cease potentially emetogenic medications (NSAIDs, antibiotics, opioids) before adding new antiemetics.
  • Aboriginal and Torres Strait Islander patients may face barriers to palliative care access; culturally safe communication about nausea management and end-of-life symptom control is essential.

Introduction & Australian Epidemiology

Nausea and vomiting are among the most prevalent and distressing symptoms experienced by patients receiving palliative care. In Australia, nausea affects approximately 40–70% of patients with advanced cancer and 30–60% of those with end-stage organ failure in the palliative phase. Uncontrolled nausea significantly impairs quality of life, reduces oral intake, contributes to cachexia, and may precipitate hospital admission — the very outcome palliative care seeks to avoid.

Unlike chemotherapy-induced nausea — for which well-established, emetogenic-risk-based algorithms exist — palliative nausea is multifactorial and often driven by a combination of the underlying disease, metabolic derangements, medications (particularly opioids), and gastrointestinal dysmotility. The Palliative Care Outcomes Collaboration (PCOC) data consistently identifies nausea as one of the top three symptoms at initial palliative care assessment in Australian specialist palliative care services.

Australian palliative care practice emphasises a cause-based assessment framework rather than a purely empirical antiemetic ladder. The Palliative Care Clinical Studies Collaborative (PaCCSC) has contributed significantly to the evidence base for antiemetic use in the palliative setting. Medication access through the Pharmaceutical Benefits Scheme (PBS) — including authority-required listings for agents such as octreotide and aprepitant — is a critical consideration in prescribing.

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Key principle: In palliative care, the goal of antiemetic therapy is symptom relief and quality of life — not necessarily complete elimination of nausea. Always balance efficacy against side-effect burden, particularly sedation and extrapyramidal effects.

This guideline covers the cause-based assessment of nausea and vomiting in the palliative setting, evidence-based antiemetic selection, specific management of bowel obstruction, and practical guidance on alternative routes of administration — a frequent challenge in patients with advanced disease.

Cause-Based Assessment

A systematic, cause-based assessment is the foundation of effective antiemetic management in palliative care. The aetiology of nausea is often multifactorial, and identifying the dominant mechanism(s) allows targeted therapy rather than empirical polypharmacy. The commonly cited "four pathways" model of nausea — cortical, vestibular, chemoreceptor trigger zone (CTZ), and peripheral (vagal / visceral) — maps onto specific antiemetic receptor targets and guides drug selection.

The Four Nausea Pathways

Pathway Common Palliative Causes Receptor Target First-Line Antiemetic
Cortical (anxiety, raised ICP, increased intracranial pressure) Brain metastases, anxiety, anticipatory nausea, raised ICP CB₁, 5-HT₃, H₁, D₂ Dexamethasone (raised ICP), benzodiazepines (anxiety-related), haloperidol
Vestibular (middle ear, cerebellum) Posterior fossa metastases, vestibular dysfunction, movement-related nausea H₁, muscarinic (M₁) Cyclizine, hyoscine hydrobromide
Chemoreceptor Trigger Zone (CTZ) Opioids, metabolic (uraemia, hypercalcaemia, hepatic failure), drugs D₂, 5-HT₃, NK₁ Haloperidol, metoclopramide, ondansetron
Peripheral / Visceral (vagal afferents, GI tract) Gastric stasis, constipation, bowel obstruction, gastric irritation, hepatomegaly, peritoneal disease 5-HT₄, D₂, 5-HT₃, motilin Metoclopramide (prokinetic), cyclizine (bowel obstruction), octreotide

Systematic Assessment Approach

When evaluating a palliative patient with nausea, consider the following checklist:

  • Medication review: Opioids (especially morphine, tramadol), antibiotics (metronidazole, erythromycin), NSAIDs, anticonvulsants (sodium valproate), digoxin, chemotherapy agents, serotonergic drugs (SSRIs + tramadol combinations). Cease or substitute where possible.
  • Constipation: Extremely common and frequently overlooked. Assess last bowel action, stool consistency, abdominal examination. Often co-exists with opioid therapy. Trial of aperients (e.g., macrogol, senna, lactulose) before escalating antiemetics.
  • Gastric stasis / gastroparesis: Early satiety, bloating, nausea worse after eating. Common with opioid use, diabetes, and upper abdominal malignancy. Trial of prokinetic (metoclopramide or domperidone).
  • Metabolic causes: Hypercalcaemia (most common paraneoplastic cause of nausea), renal failure (uraemia), hepatic failure, adrenal insufficiency. Address underlying cause where feasible; haloperidol or ondansetron as adjunct.
  • Raised intracranial pressure: Brain metastases — headache worse in morning, papilloedema, neurological focal signs. Dexamethasone 8–16 mg daily is urgent.
  • Bowel obstruction: Colicky or continuous abdominal pain, distension, absolute constipation, vomiting (may be faeculent). See dedicated Bowel Obstruction section.
  • Hepatomegaly / peritoneal disease: Stretch of the liver capsule or peritoneum causes nausea via vagal afferents. Dexamethasone 4–8 mg daily.
  • Mucositis / oral candidiasis: Oral causes may contribute; assess mouth and treat appropriately.
  • Psychological / anticipatory: Anxiety, depression, fear. Consider anxiolytics, non-pharmacological strategies.
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Do not forget constipation: Constipation is the single most common reversible cause of nausea in opioid-treated palliative patients. Always perform a rectal examination or review bowel chart before escalating antiemetics. Treating constipation alone may resolve nausea in up to 50% of cases.

Investigations

Investigations in palliative care should be targeted and proportionate to the patient's goals of care. Not all patients will require or benefit from blood tests. Consider investigations when the result will change management.

Essential Focused history & medication review Identify emetogenic drugs, constipation, timing of nausea relative to meals and opioids
Available Serum calcium (corrected) Hypercalcaemia of malignancy — common, treatable cause. MBS item 66551.
Available Urea, creatinine, eGFR Assess uraemia as a nausea driver; guide renal dose adjustments. MBS item 66512.
Available LFTs (bilirubin, ALT, ALP, GGT) Hepatic metastases, hepatic failure. MBS item 66515.
Available Abdominal X-ray If bowel obstruction suspected — confirm dilated loops, fluid levels. MBS item 57711.
Referral CT abdomen/pelvis If surgical or interventional options are being considered. MBS item 56100.
Specialist MRI brain If raised ICP suspected from brain metastases. MBS item 63001.

Antiemetic Selection

Antiemetic selection in palliative care is guided by the identified or suspected cause of nausea (pathway-based approach) rather than a fixed step-up ladder. However, when the cause remains unclear or multiple mechanisms co-exist, a rational empiric approach may be necessary. The following agents represent the core palliative antiemetic formulary in Australia.

Core Antiemetic Agents

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Metoclopramide
Maxolon® · Pramin® · Prokinetic / D₂ antagonist
Indication First-line for gastric stasis, opioid-induced nausea (CTZ and prokinetic), gastroparesis
Adult dose (oral) 10 mg PO TDS, 15–30 min before food; max 40 mg/day
Adult dose (SC) 10 mg SC TDS or 30–60 mg/24 h via CSCI (syringe driver)
Paediatric dose 0.1–0.15 mg/kg/dose PO/SC TDS–QID (max 0.5 mg/kg/day)
Renal adjustment eGFR <30: reduce dose by 50% (5 mg PO TDS or 15 mg/24 h CSCI)
Key side effects Extrapyramidal symptoms (dose-related, max 40 mg/day), drowsiness, akathisia. Avoid in bowel obstruction (prokinetic effect may worsen colic).
PBS status ✔ PBS General Benefit
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Haloperidol
Serenace® · Haldol® · D₂ antagonist (low-dose)
Indication First-line for chemical/metabolic nausea (uraemia, hypercalcaemia, hepatic failure), drug-induced nausea, opioid-induced nausea (CTZ)
Adult dose (oral) 0.5–1.5 mg PO nocte or BD; titrate to max 5 mg/day for nausea
Adult dose (SC) 0.5–1.5 mg SC BD or 1.5–5 mg/24 h via CSCI
Paediatric dose 0.01–0.025 mg/kg/dose PO/SC BD–TDS (max 0.1 mg/kg/day)
Renal adjustment No specific adjustment; use with caution in renal impairment
Key side effects Sedation, QTc prolongation, extrapyramidal effects at higher doses. Avoid in Lewy body dementia. ECG monitoring if dose >5 mg/day or cardiac history.
PBS status ✔ PBS General Benefit
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Cyclizine
Valoid® · Antihistamine (H₁ antagonist)
Indication First-line for vestibular nausea, bowel obstruction, motion-related nausea, raised ICP adjunct
Adult dose (oral) 50 mg PO TDS (up to QID if needed)
Adult dose (SC) 50 mg SC TDS or 150 mg/24 h via CSCI
Paediatric dose Not recommended <6 years; 6–12 years: 25 mg PO TDS
Renal adjustment No specific adjustment required
Key side effects Drowsiness, anticholinergic effects (dry mouth, urinary retention, constipation). May precipitate confusion in elderly. Avoid mixing with other anticholinergics.
PBS status ✔ PBS General Benefit
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Ondansetron
Zofran® · 5-HT₃ antagonist
Indication Chemotherapy/radiotherapy-induced nausea; refractory nausea when haloperidol and metoclopramide ineffective
Adult dose (oral) 4–8 mg PO BD–TDS (max 32 mg/day in oncology setting)
Adult dose (SC) 4–8 mg SC BD or 16–32 mg/24 h via CSCI
Paediatric dose 0.1–0.15 mg/kg/dose PO/SC/IV BD–TDS (max 16 mg/day)
Renal adjustment No dose adjustment required; severe hepatic failure: max 8 mg/day
Key side effects Constipation (significant — can worsen opioid-induced constipation), headache, QTc prolongation at high doses. Avoid combining with aprepitant without monitoring.
PBS status ✔ PBS General Benefit
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Dexamethasone
Dexsol® · Corticosteroid (anti-inflammatory)
Indication Raised ICP (brain metastases), hepatomegaly, bowel obstruction (reduces oedema), adjuvant antiemetic in combination regimens
Adult dose 4–16 mg PO/SC daily (morning dosing preferred); raised ICP: 8–16 mg/day initial, taper to 4–8 mg/day maintenance
Paediatric dose 0.15–0.6 mg/kg/day PO/SC (max 10 mg/day); discuss with paediatric palliative specialist
Renal adjustment No specific adjustment; use lowest effective dose
Key side effects Hyperglycaemia, myopathy, insomnia, gastritis (co-prescribe PPI), adrenal suppression with prolonged use. Taper if used >3 weeks.
PBS status ✔ PBS General Benefit
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Domperidone
Motilium® · D₂ antagonist / Prokinetic (peripheral)
Indication Alternative prokinetic to metoclopramide for gastric stasis; does not cross BBB so fewer extrapyramidal effects
Adult dose 10–20 mg PO QID (before meals and at bedtime); max 80 mg/day
Renal adjustment eGFR <30: reduce frequency to BD–TDS
Key side effects QTc prolongation — avoid in cardiac arrhythmias or with QTc-prolonging agents. Not available SC (oral only in Australia).
PBS status ✔ PBS General Benefit
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Aprepitant
Emend® · NK₁ receptor antagonist
Indication Refractory nausea despite first-line agents; chemotherapy-induced nausea (highly emetogenic regimens). Limited evidence in palliative non-chemo nausea but increasing use.
Adult dose 125 mg PO Day 1, then 80 mg PO Days 2–3 (acute chemo); or 80 mg PO daily ongoing for refractory nausea
Renal adjustment No dose adjustment required
Key side effects Fatigue, hiccoughs, constipation. Significant CYP3A4 inhibitor — check drug interactions (warfarin, dexamethasone dose reduction needed).
PBS status ⚠ PBS Authority Required — for chemotherapy-induced nausea with highly emetogenic protocols
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Levomepromazine
Nozinan® · Phenothiazine (broad-spectrum antiemetic)
Indication Refractory nausea in palliative care when other agents fail; broad-spectrum D₂, H₁, 5-HT₂, muscarinic antagonist
Adult dose 6.25–12.5 mg PO/SC BD–TDS; titrate cautiously (max 50 mg/day for nausea)
Renal adjustment Use with caution; start at lower end of dosing range
Key side effects Significant sedation, orthostatic hypotension, anticholinergic effects. Reserved for refractory cases or when sedation is acceptable (e.g., end of life).
PBS status ✔ PBS General Benefit

Antiemetic Selection by Cause — Quick Reference

Opioid-induced nausea (first-line)
Haloperidol 0.5–1.5 mg nocte OR metoclopramide 10 mg TDS
5–7 days then review (tolerance develops)
If gastric stasis suspected → metoclopramide preferred (prokinetic)
Chemical / metabolic (uraemia, hypercalcaemia, liver failure)
Haloperidol 1–1.5 mg daily
Ongoing; treat underlying cause
Correct hypercalcaemia urgently if Ca²⁺ >3.0 mmol/L
Gastric stasis / gastroparesis
Metoclopramide 10 mg PO TDS (before meals)
Ongoing
Domperidone as alternative if extrapyramidal effects; max 40 mg/day metoclopramide
Vestibular / movement-related
Cyclizine 50 mg TDS
Ongoing PRN
Hyoscine hydrobromide as alternative; sedation risk
Raised intracranial pressure
Dexamethasone 8–16 mg daily (with PPI cover)
Ongoing; taper when stable
Urgent neurosurgical referral if acute hydrocephalus
Hepatomegaly / peritoneal disease
Dexamethasone 4–8 mg daily
Trial for 3–5 days; continue if effective
May take 24–48 h for full effect
Constipation-related
Aperient therapy (see bowel care); NOT antiemetics first
Ongoing bowel regimen
Macrogol, senna, lactulose, or rectal intervention as indicated
Refractory nausea (multi-drug failure)
Levomepromazine 6.25–12.5 mg BD–TDS OR aprepitant
Ongoing; monitor sedation
Consider specialist palliative care advice. May add synergistic agents (e.g., haloperidol + cyclizine + dexamethasone).
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Practical tip: Combining antiemetics that act at different receptor pathways (e.g., haloperidol + cyclizine + dexamethasone) is common practice in refractory nausea and is generally more effective than escalating a single agent. Always review for additive side effects (sedation, anticholinergic burden, QTc prolongation).

Bowel Obstruction

Malignant bowel obstruction (MBO) is a common and distressing complication of advanced intra-abdominal and pelvic cancers. It affects 10–28% of patients with advanced ovarian cancer, 10–15% with colorectal cancer, and significant proportions with other abdominal malignancies. In the palliative context, the management goal is symptom control — particularly nausea, vomiting, colic, and pain — rather than surgical decompression, unless the patient is a surgical candidate with a realistic functional prognosis.

Pathophysiology of Malignant Bowel Obstruction

MBO causes nausea and vomiting through several mechanisms: mechanical obstruction leading to proximal bowel distension, increased secretions proximal to the obstruction, bacterial overgrowth, and activation of vagal and splanchnic afferents. The vomiting is often large-volume and may become faeculent if distal obstruction is present. Paradoxically, some patients with high obstruction may have continued passage of flatus or stool from distal bowel contents.

Assessment

  • Clinical: Colicky or continuous abdominal pain, abdominal distension, vomiting (may be faeculent), absolute constipation (no flatus), tinkling bowel sounds (may be absent late).
  • Abdominal X-ray: Dilated small bowel loops (valvulae conniventes visible), air-fluid levels, absence of gas in the rectum. First-line imaging. MBS item 57711.
  • CT abdomen/pelvis: If surgical decision is being considered or the level of obstruction needs clarification. MBS item 56100.
  • Goals of care discussion: Essential before any investigation. Clarify whether the patient wishes to pursue surgical intervention or purely conservative symptom management.

Conservative (Medical) Management

For the majority of patients with MBO who are not surgical candidates, a combination pharmacological approach addresses nausea, vomiting, and colic:

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Do NOT use metoclopramide or domperidone in complete bowel obstruction. Prokinetic agents may increase peristalsis proximal to the obstruction, worsening colic, pain, and risk of perforation. This is one of the most important safety considerations in palliative bowel obstruction management.

Standard Antiemetic Regimen for Inoperable MBO

1
Cease oral intake if vomiting is persistent
Nil by mouth (NBM) with IV/SC fluid replacement if the patient wishes; some patients prefer small sips for comfort. Mouth care is essential.
2
Antiemetic: Cyclizine 150 mg/24 h CSCI
H₁ antagonist — controls nausea and vomiting from vagal stimulation. First-line for MBO-related nausea. May be given SC bolus 50 mg TDS if no syringe driver available.
3
Anti-secretory: Octreotide 300–600 mcg/24 h CSCI OR Hyoscine butylbromide 60–120 mg/24 h CSCI
Reduces intestinal secretions, decreasing vomiting volume. Octreotide is generally preferred for persistent high-volume vomiting; hyoscine butylbromide is cheaper and readily available. Start hyoscine butylbromide if octreotide not immediately available.
4
Adjuvant: Dexamethasone 6–8 mg SC daily
Reduces tumour-related oedema at the obstruction site, may improve symptoms. Consider in all MBO cases unless contraindicated (e.g., GI perforation risk, uncontrolled diabetes). Co-prescribe PPI for gastric protection.
5
Pain management: Opioid via CSCI
Morphine or fentanyl SC for colicky and continuous pain. Add hyoscine hydrobromide (0.2–0.4 mg/24 h CSCI) if secretions are copious despite octreotide / hyoscine butylbromide ("death rattle" if terminal phase).

Octreotide Details

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Octreotide
Sandostatin® · Somatostatin analogue
Indication Reduction of intestinal secretions in inoperable MBO; high-volume vomiting not controlled by standard antiemetics
Adult dose Start 300 mcg/24 h CSCI; titrate to 600–900 mcg/24 h if needed. SC bolus: 100–200 mcg TDS as alternative.
Renal adjustment No adjustment required
Key side effects Abdominal discomfort, steatorrhoea, hyperglycaemia/hypoglycaemia, gallstones (long-term). Pain at injection site with SC bolus.
PBS status ⚠ PBS Authority Required — for treatment of symptoms associated with inoperable bowel obstruction secondary to intra-abdominal malignancy

Nasogastric Tube (NGT) Considerations

Nasogastric decompression may be required if pharmacological management fails to control vomiting. However, NGT placement should be considered carefully in palliative patients — it is uncomfortable, may require repeated insertion, and conflicts with comfort-focused goals in many cases. Reserve NGT for:

  • Patients awaiting a surgical decision where aspiration risk is high
  • Refractory vomiting despite maximum medical therapy (as a bridge to symptom control)
  • Short-term use only with clear review plan (24–48 h)
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Avoid prolonged NGT use in palliative patients. Long-term NGT use is inconsistent with comfort-focused care. If vomiting cannot be controlled medically and surgery is not an option, discuss the patient's priorities and consider whether the dying process is approaching — where comfort measures, including mouth care and SC antiemetics, may be more appropriate.

Surgical Options

Surgical intervention (bowel resection, bypass, or stenting) may be appropriate for a small minority of patients with MBO who have a reasonable performance status and expected survival >60 days. Decision-making should involve:

  • Multidisciplinary discussion (surgical oncology, palliative care, medical oncology)
  • Assessment of performance status (ECOG 0–2 more likely to benefit)
  • Patient's goals of care and understanding of risks (morbidity 30–50%, mortality 10–20% for palliative surgery)
  • Self-expanding metallic stents (SEMS) for colonic obstruction — less invasive, shorter recovery, suitable for patients with limited prognosis. Available at major Australian tertiary centres.

Route of Administration

As patients progress through the palliative phase, oral medication administration becomes increasingly unreliable due to nausea, vomiting, dysphagia, reduced consciousness, or bowel obstruction. Australian palliative care practice is highly developed in alternative route management, particularly the use of continuous subcutaneous infusion (CSCI) via syringe drivers.

Route Selection Principles

Preferred
Oral (PO)
First-line whenever patient can swallow tablets or liquid. Most convenient, most familiar, least invasive.
Setting: Home, hospice, hospital — all settings
Alternative
Subcutaneous (SC) bolus
When oral route is unreliable. Suitable for intermittent dosing (e.g., metoclopramide 10 mg SC TDS). Uses 25–27G butterfly needle or Insuflon® port.
Setting: Home, hospice, hospital
Continuous
CSCI via syringe driver
Continuous subcutaneous infusion over 24 hours. Standard of care for persistent nausea in Australia. Uses McKinley T34® or CADD-MS 3® pump. Allows combination of multiple drugs in one syringe.
Setting: All settings including community palliative care

Subcutaneous Compatibility — Syringe Driver

When combining medications in a syringe driver, compatibility is essential. The following antiemetics are commonly used in CSCI and have established compatibility data in Australian palliative care practice:

Drug Typical CSCI Dose (24 h) Compatible With Incompatible With
Metoclopramide 30–60 mg/24 h Morphine, haloperidol, dexamethasone, hyoscine butylbromide, cyclizine, ondansetron, fentanyl, midazolam Diazepam (precipitation), chlorpromazine
Haloperidol 1.5–5 mg/24 h Metoclopramide, morphine, cyclizine, dexamethasone, hyoscine butylbromide, midazolam, fentanyl Ondansetron (risk of precipitation at high concentrations), diazepam
Cyclizine 150 mg/24 h Metoclopramide, haloperidol, morphine, hyoscine butylbromide, dexamethasone, fentanyl Ondansetron (precipitation), diazepam
Ondansetron 16–32 mg/24 h Metoclopramide, morphine, dexamethasone, midazolam, fentanyl Haloperidol, cyclizine (precipitation risk at high concentrations)
Dexamethasone 4–16 mg/24 h Most antiemetics and opioids — highly compatible Few known incompatibilities; avoid mixing with diazepam
Octreotide 300–600 mcg/24 h Morphine, metoclopramide, haloperidol, hyoscine butylbromide Limited data with cyclizine; use separately if uncertain
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Syringe driver diluent: Use Water for Injections or 0.9% NaCl as the standard diluent for CSCI. Always check the specific compatibility reference used by your palliative care service (e.g., the Palliative Care Guidelines — Syringe Driver data or Syringe Driver Continuous Subcutaneous Infusions — Australian compatibility charts). Concentrations vary by drug — consult your local palliative care guidelines or clinical pharmacist.

Other Routes

  • Sublingual (SL): Useful for some agents (e.g., ondansetron ODT — orally disintegrating tablet). Avoid if mucositis is present. Limited antiemetic options via this route.
  • Transdermal: Granisetron transdermal patch (Sancuso® 3.1 mg/24 h, applied 24–48 h before chemotherapy) — PBS authority required for chemotherapy-induced nausea. Not widely used in general palliative nausea.
  • Rectal (PR): An option when SC is not available. Metoclopramide 20 mg PR TDS or haloperidol PR. Limited by patient comfort and nursing home availability.
  • Intravenous (IV): Less commonly used in community settings; reserved for inpatients with IV access. Same doses as SC for most agents. Ondansetron may be given IV push.
  • Nebulised: Not applicable to antiemetics.

Practical Tips for CSCI Management

  • Change the SC site every 5–7 days (or sooner if redness, swelling, or leakage). Preferred sites: anterior chest wall, anterior thigh, upper arm, anterior abdominal wall (avoid oedematous areas).
  • Use a 25G butterfly needle or dedicated SC port (Insuflon®). The McKinley T34 syringe driver is the most commonly used pump in Australian community palliative care.
  • Calculate the CSCI volume to be ≤2 mL for a 2 mL syringe (preferred) or ≤4 mL for a larger syringe, depending on pump type.
  • Convert from oral to SC doses using the approximate SC:PO ratio of 1:1 for most antiemetics (metoclopramide, haloperidol, cyclizine). This is simpler than opioid conversion ratios.
  • When stopping the syringe driver (e.g., patient stabilises and can take oral medications), overlap oral dosing 1–2 hours before the CSCI completes to prevent breakthrough nausea.

Monitoring

Monitoring in palliative care focuses on symptom response, side-effect burden, and alignment with patient goals — not on biochemical targets or imaging surveillance unless results will change management.

Clinical Monitoring Parameters

  • Nausea severity: Use a validated tool such as the Edmonton Symptom Assessment System — Revised (ESAS-r) nausea item (0–10 numeric rating scale). Assess at each review and 24–48 h after antiemetic initiation or dose change.
  • Vomiting frequency: Record number of episodes per 24 h. Aim for <2 episodes/day as a realistic target.
  • Oral intake: Document fluid and food tolerance. Refer to dietitian if oral intake is maintained.
  • Bowel function: Regular bowel chart. Monitor for constipation (especially with ondansetron use) and diarrhoea.
  • Side effects: Specifically monitor for extrapyramidal symptoms (metoclopramide, haloperidol), sedation (cyclizine, levomepromazine), constipation (ondansetron), QTc prolongation (haloperidol, ondansetron, domperidone), and hyperglycaemia (dexamethasone, octreotide).
  • ECG: Consider baseline and follow-up ECG if using haloperidol >5 mg/day, ondansetron >16 mg/day, or domperidone — particularly in patients with cardiac history or electrolyte derangements.
  • Electrolytes: Monitor potassium, magnesium, and calcium if on QTc-prolonging agents or if metabolic causes are being treated.
  • CSCI site: Inspect daily for inflammation, leakage, or displacement. Document on syringe driver chart.

Escalation and Review Triggers

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Seek specialist palliative medicine advice if: nausea persists despite dual antiemetic therapy at optimal doses for >48 h; bowel obstruction is newly diagnosed; the patient is deteriorating rapidly; or you are unsure about syringe driver drug compatibility. Contact your state palliative care consultancy service (e.g., Palliative Care Australia Clinical Advisory Service, or Queensland QPPCC, Victorian PCOC, NSW CCCS).

Special Populations

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Pregnancy

Ondansetron
Use only if benefit outweighs risk. First trimester use associated with small increased risk of cleft palate. Preferred alternatives: metoclopramide (Category A), cyclizine (Category A in Australian classification), doxylamine + pyridoxine (Category A). Discuss with obstetric team.
Metoclopramide
Category A — preferred prokinetic in pregnancy. Short-term use only to minimise extrapyramidal risk.
Haloperidol
Category C — use only if no alternatives. Neonatal extrapyramidal effects reported.
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Paediatrics

Ondansetron
First-line antiemetic in paediatric palliative care. 0.1–0.15 mg/kg/dose PO/SC/IV BD–TDS. Well tolerated. Available as oral liquid (PBS listed).
Metoclopramide
0.1–0.15 mg/kg/dose. Higher extrapyramidal risk in children — use second-line. Avoid in infants <1 year.
Dexamethasone
0.15–0.6 mg/kg/day. Discuss with paediatric palliative care specialist. Monitor blood glucose.
CSCI (syringe driver)
May be used in paediatric palliative care with appropriately trained staff. Dose calculations by weight; volumes may be very small. Engage paediatric palliative care team early (e.g., Bear Cottage, QLD Children's Palliative Care Service).
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Elderly

General principles
Increased sensitivity to sedation, anticholinergic effects, and extrapyramidal symptoms. Start at lowest effective dose. Avoid cyclizine in cognitively impaired elderly (may worsen confusion). Haloperidol is generally well tolerated at low doses (0.5 mg nocte).
QTc monitoring
Higher baseline QTc risk. ECG recommended if using haloperidol, ondansetron, or domperidone in patients >75 years or with cardiac comorbidities.
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Renal Impairment

Metoclopramide
Reduce dose by 50% if eGFR <30 mL/min. Accumulation increases extrapyramidal risk.
Haloperidol
No specific adjustment but start low; increased sensitivity in uraemia.
Ondansetron
No dose adjustment required. Safe in renal impairment.
Uraemic nausea
Haloperidol 0.5–1 mg nocte is first-line. Address reversible causes (phosphate binders, ensure adequate dialysis in ESKD patients still receiving renal replacement therapy).
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Hepatic Impairment

Ondansetron
Max 8 mg/day in severe hepatic failure (reduced clearance).
Haloperidol
Use with caution; hepatic metabolism. Start low, titrate slowly. Monitor for sedation and QTc.
Dexamethasone
Effective for nausea from hepatomegaly. Use lowest effective dose. Monitor blood glucose.
Avoid
Metoclopramide in hepatic encephalopathy — may worsen extrapyramidal features. Haloperidol at low doses is generally preferred.
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Immunocompromised

General principles
Consider infection as a cause of nausea (e.g., CMV colitis, Clostridioides difficile, neutropenic enterocolitis). Review for drug-drug interactions with immunosuppressants (e.g., ondansetron may affect tacrolimus levels).
Corticosteroids
Dexamethasone may provide antiemetic benefit but consider interaction with existing immunosuppressive regimen. May mask infection.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of advanced disease and symptom burden, yet access to specialist palliative care remains significantly lower than for non-Indigenous Australians. The AIHW reports that Indigenous Australians are 1.5 times more likely to die from cancer and have higher rates of end-stage renal disease and heart failure — all conditions that cause nausea in the palliative phase.

Cultural safety, community engagement, and shared decision-making are essential when managing symptoms in Indigenous Australians receiving palliative care.

Access to specialist palliative care
Indigenous Australians in remote and very remote areas (particularly NT, WA, QLD) have limited access to specialist palliative care services. Primary care clinicians, Remote Area Nurses (RANs), and Aboriginal Health Practitioners (AHPs) are often the main providers of palliative symptom management, including antiemetics. Telehealth palliative care consultations are increasingly available through state palliative care services.
Medication access in remote communities
Community-controlled health services (ACCHSs) maintain essential medicine supplies (Close the Gap PBS co-payment). Metoclopramide, haloperidol, cyclizine, dexamethasone, and ondansetron are generally available. Octreotide and aprepitant may require individual patient supply or retrieval from urban centres. Syringe drivers (McKinley T34) are available through most state palliative care services for community use, including remote communities.
Cultural considerations in symptom communication
Nausea and vomiting may not always be volunteered; direct questioning is required. The concept of "shame" may prevent patients from reporting symptoms. Use culturally appropriate communication tools and involve family members or Aboriginal Health Workers in symptom assessment. Avoid assumptions about understanding of medical terms — use plain language and visual aids where possible.
Sorry Business and end-of-life care
During Sorry Business, community and family obligations may take priority over medication schedules. Flexible approaches to antiemetic timing are important. SC routes and syringe drivers are particularly valuable when family and community commitments make regular oral dosing impractical.
Traditional medicine interactions
Some patients may use bush medicine alongside prescribed antiemetics. Open, non-judgemental discussion about concurrent use is important. Be aware of potential pharmacological interactions (e.g., some traditional plants may have anticholinergic or hepatic enzyme effects). Coordinate with the patient's community health team.
Preferred place of death
Many Indigenous Australians express a strong preference to die on Country. Effective symptom management, including reliable nausea control, is critical to enabling this. Community palliative care teams, Remote Area Nurses, and ACCHSs play a central role. The National Palliative Care Strategy (2018) identifies improving access for Indigenous Australians as a priority.
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Key resource: The Palliative Care Australia publication "Palliative Care and Aboriginal and Torres Strait Islander People" and the RHDAustralia guidelines provide practical frameworks for culturally safe palliative symptom management in remote communities. The Australian Indigenous HealthInfoNet (healthinfonet.ecu.edu.au) provides evidence summaries and resources.

📚 References

  1. 1. Currow DC, Agar M, To THM, et al. Ondansetron in the management of nausea in palliative care: a systematic review. J Pain Symptom Manage. 2008;36(2):195–201.
  2. 2. Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243–259.
  3. 3. National Health and Medical Research Council (NHMRC). Clinical Practice Guidelines for the Management of Uncommon Cancers. Canberra: NHMRC; 2023.
  4. 4. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Department of Health; 2019.
  5. 5. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. AIHW Cat. No. HWL 2. Canberra: AIHW; 2023.
  6. 6. Hardy JR, Ling J, Mansi J, et al. Pitfalls in placebo-controlled trials in palliative care: dexamethasone for the palliation of malignant bowel obstruction. Palliat Med. 1998;12(1):45–49.
  7. 7. Mercadante S, Ferrera P, Villari P, et al. Aggressive pharmacological treatment for reversing malignant bowel obstruction. J Pain Symptom Manage. 2004;28(4):412–416.
  8. 8. Clark K, Lam LT, Agar M, et al. The impact of opioids on the management of nausea and vomiting in patients with cancer. J Pain Symptom Manage. 2010;40(4):628–634.
  9. 9. Davis MP, Hallerberg G; Multinational Association of Supportive Care in Cancer. A systematic review of the treatment of nausea and/or vomiting in cancer. Crit Rev Oncol Hematol. 2010;74(2):107–116.
  10. 10. Royal Australian College of General Practitioners (RACGP). Providing end-of-life care: A guide for general practitioners. Melbourne: RACGP; 2023.
  11. 11. Feuer DJ, Broadley KE. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynastric and gastrointestinal cancer. Cochrane Database Syst Rev. 2000;(4):CD002764.
  12. 12. O'Mahony S, Ferrell B, Hurzeler T, et al. Palliative care clinical studies collaborative (PaCCSC): an Australian research initiative. J Palliat Med. 2012;15(1):10–13.
  13. 13. Palliative Care Outcomes Collaboration (PCOC). National Bulletin — Data to December 2023. Wollongong: University of Wollongong; 2024.
  14. 14. McCallum P, Riddington M, Sheehan S. Syringe driver continuous subcutaneous infusions in palliative care — compatibility guide. 5th ed. Christchurch: Palliative Care Pharmacy Network; 2023.
  15. 15. Australian Indigenous HealthInfoNet. Overview of Aboriginal and Torres Strait Islander health status 2023. Perth: Edith Cowan University; 2024.
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. 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. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 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. 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. 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. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 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. 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. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 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. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 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. 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. 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. 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. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 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. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 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. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 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. 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. 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
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. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 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. 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. 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. 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. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 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. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 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. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 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. 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. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).