The written exam marks the current Australian answer. Most of what changes in a month is small and specific: a funded group narrows, a drug is listed, a brand is deleted, a threshold moves, a guideline edition adds a clarification. Each one is a potential question, because a candidate who learned the old answer gets it wrong with confidence. This is the first of a monthly series: what changed in Australian guidance in October 2026, what the previous answer was, and what the candidate is now expected to say. Every item below was opened at its source in the week of writing; where a source could not be opened, the item was left out.
1. COVID-19 vaccines move to the National Immunisation Program, with four funded groups
What changed. On 1 October 2026 COVID-19 vaccination moved from the stand-alone National COVID-19 Vaccine Program into the National Immunisation Program (NIP) and stopped being universally funded. Free doses are now only for:
- adults aged 75 years and over, one dose every 6 months;
- adults aged 65 to 74 years, one dose every 12 months;
- Aboriginal and Torres Strait Islander people aged 50 to 74 years, one dose every 12 months;
- adults aged 18 years and over with severe immunocompromise, one dose every 12 months.
Everyone else can buy the vaccine privately after discussion with their provider. States and territories now run ordering, distribution and reporting.
What it means for the exam. The old answer, that COVID-19 vaccination was recommended and funded for adults with chronic disease, is now wrong on funding. A 60 year old with diabetes or COPD is no longer funded unless they are Aboriginal or Torres Strait Islander or severely immunocompromised. The intervals are part of the rule: a dose sooner than the funded interval is a private dose. The Australian Prescriber summary does not define severe immunocompromise, so the Australian Immunisation Handbook's list is where that answer lives.
Source: Australian Prescriber 2026;49:201, 6 October 2026.
2. The ASCIA adult penicillin allergy guideline
What changed. ASCIA, the National Allergy Council and the National Allergy Centre of Excellence published a guideline for adult penicillin allergy in Australia and New Zealand (Lucas and colleagues, J Allergy Clin Immunol Glob 2026;5:100784), developed with the AGREE II framework and a Delphi panel of 27 drug allergy experts, with 37 recommendations. It updates ASCIA's 2020 consensus statement. Patients with a penicillin allergy label are sorted into risk groups: minimal risk is delabelled on history alone; low risk goes to direct oral challenge, which can be done in the community; intermediate and high risk are referred to a specialist, and community testing is restricted to the minimal and low risk groups.
Numbers worth carrying. About 9 per cent of adults carry a penicillin allergy label, but fewer than 10 per cent of those formally tested are truly allergic. Cross-reactivity with aminocephalosporins is about 16.5 per cent, with less similar first and second generation cephalosporins 2.1 to 2.6 per cent, and low with third and later generations. In one review, 4.1 per cent (10 of 243) of delabelled people reacted to a therapeutic penicillin course 2 to 10 years later, so delabelling is not a guarantee.
What it means for the exam. A remote benign rash is a direct oral challenge, not skin testing; a recent rash or an IgE-type reaction is a referral; anaphylaxis, a severe cutaneous reaction or a reaction of unknown nature is never community tested. The time cut-off for a benign rash is in the guideline's risk table, which should be read directly.
3. Rheumatic fever and rheumatic heart disease: Edition 3.4
What changed. The Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease is now Edition 3.4 (RHDAustralia, October 2026). Its October updates add definitions of acute rheumatic fever, rheumatic heart disease and secondary prophylaxis; add a footnote to the Strep A skin sore antibiotic table cautioning against cotrimoxazole in pregnancy (cefalexin 1 g twice daily for 5 days is the alternative); clarify the need for specialist review before ceasing secondary prophylaxis; add a checklist of the steps before ceasing; and settle post-streptococcal reactive arthritis.
The settled answer. With a normal echocardiogram and definite, possible and probable ARF ruled out: in low risk groups, no secondary prophylaxis and a repeat echocardiogram in one year; in high risk groups, secondary prophylaxis for 2 years with yearly echocardiography, ceasing after 2 years if the echocardiogram is still normal, with a further echocardiogram 1 year later. The guideline adds that the diagnosis should rarely, if ever, be made in high risk populations, and with caution in low risk ones, because some such patients later have episodes of ARF.
What it means for the exam. Post-streptococcal reactive arthritis has a risk-group answer. Remember too that the diagnostic thresholds differ by risk group: in low risk groups fever is 38.5 degrees or more and polyarthralgia is only a minor manifestation; in high risk groups fever is 38.0 or more, can be counted on a reliable history, and polyarthralgia can be a major manifestation. Australia defines high risk by an ARF incidence above 30 per 100,000 per year in 5 to 14 year olds or an all-age RHD prevalence above 2 per 1,000.
4. Tofersen on the PBS, and three deletions notified
What changed. Tofersen (Qalsody), an intrathecal antisense oligonucleotide that lowers SOD1 protein, was PBS listed on 1 October 2026 for amyotrophic lateral sclerosis under the Section 100 Highly Specialised Drugs Program (Authority Required, with initial, continuing and grandfather phases). The PBAC's recommendation (March 2026) was for ALS with a pathogenic SOD1 variant. It is the first SOD1-targeted therapy on the PBS, not the first ALS drug: riluzole and edaravone are listed, and the PBAC advised that the tofersen listing would need changes to the edaravone restrictions to prevent combined use. The authority criteria are read on the PBS item page when prescribing and are not reproduced here.
The PBS Summary of Changes also gives advance notice of item deletions: glibenclamide (Daonil, the only listed brand) and eprosartan (Teveten, Teveten Plus) on 1 December 2026, and insulin detemir (Levemir) on 1 January 2027.
What it means for the exam. A motor neurone disease stem now has a genetic branch: ask about family history and SOD1 testing. The deletions matter for a prescribing question: glibenclamide leaves the PBS, and a patient on detemir needs a plan to change basal insulin before January. An item deletion removes the drug in that form; a brand deletion (the Zytiga brand of abiraterone on the same notice) removes one product while other brands stay.
5. Therapeutic Guidelines: hypophosphataemia rewritten
What changed. The October 2026 eTG release marks Hypophosphataemia (Bone and Metabolism) as a practice-changing update. Management of acute hypophosphataemia now covers mild and moderate as well as severe presentations, with new oral and intravenous phosphate recommendations, a table for choosing an intravenous formulation that lists sodium dihydrogen phosphate first line, and a new recommendation for calcitriol in FGF23-mediated hypophosphataemia. The doses are behind the eTG subscription.
What it means for the exam. An intravenous replacement question keys sodium dihydrogen phosphate; and a stem with a raised or inappropriately normal FGF23 (tumour-induced osteomalacia, X-linked hypophosphataemia, recent ferric carboxymaltose) now has calcitriol alongside phosphate, because FGF23 suppresses 1-alpha hydroxylase as well as driving phosphate loss.
6. Hepatitis B: test every adult, and the end of s100 accreditation
What changed. An Australian Prescriber review (Davies, Capati and Allard, Aust Prescr 2026;49:160-7, 6 October 2026) sets out the Fourth National Hepatitis B Strategy's priority action of universal adult testing: every adult should know their hepatitis B status, with HBsAg, anti-HBs and anti-HBc added to a request form with consent, regardless of vaccination history. It reports an estimated 227,000 Australians with chronic hepatitis B, about one in three unaware, only one in four in guideline-based care and about 13 per cent on treatment, with a prevalence of 3.4 per cent among Aboriginal and Torres Strait Islander people against 0.8 per cent nationally. Specialist accreditation for prescribing hepatitis B antivirals was removed on 1 September 2026: any medical practitioner or authorised nurse practitioner can now prescribe subsidised entecavir or tenofovir.
Numbers worth carrying. Hepatocellular carcinoma surveillance (six-monthly ultrasound, with alpha-fetoprotein) is for people with cirrhosis or a family history of liver cancer or cirrhosis; Asian-Pacific men from 40 and women from 50; people from sub-Saharan Africa from 20; and Aboriginal and Torres Strait Islander people from 50, or from 40 in high-risk genotype areas such as the Northern Territory. In pregnancy, tenofovir disoproxil is considered for a viral load above 200,000 IU/mL, from 28 to 32 weeks until 4 weeks after delivery, with immunoglobulin and vaccine for the baby at birth.
What it means for the exam. The test for an adult of unknown status is the three-marker panel, not HBsAg alone; interpreting the pattern is the skill behind it; and the prescriber question no longer has an "accredited s100 prescriber" answer. The PBS treatment criteria exist (the article's Table 3 reproduces them) and are read on the PBS item page, not memorised.
7. ICRAKI: the first dialysis modality in critically ill acute kidney injury
What changed. ICRAKI (N Engl J Med 2026;395:1677-90, 14 October) randomised 554 critically ill adults with acute kidney injury needing kidney replacement therapy to intermittent haemodialysis or continuous therapy as the initial modality. It was stopped early for a sustained mortality signal. A major adverse kidney event by day 90 occurred in 78.1 against 71.6 per cent (adjusted absolute difference 6.28 percentage points, 95 per cent CI minus 1.22 to 13.79), so non-inferiority was not shown; death by day 90 was 63.1 against 53.5 per cent (hazard ratio 1.30, 95 per cent CI 1.04 to 1.63).
What it means for the exam. There is no separate Australian guideline on the choice of modality; practice follows KDIGO 2012, which calls the two complementary and suggests continuous therapy for haemodynamic instability or acute brain injury. ICRAKI is one open-label trial, stopped early, with mortality a secondary outcome, but it is the most recent large direct comparison and it favours continuous therapy as the first modality in the critically ill. In a viva, state the guideline, state the trial with its limits, and give a decision.
8. LEAP-Block: the pacing lead in heart block with a preserved ejection fraction
What changed. LEAP-Block (JAMA, 28 October 2026) randomised 499 patients with atrioventricular block, an ejection fraction of 50 per cent or more and an expected pacing burden above 40 per cent to left bundle branch area pacing or right ventricular pacing. At 24 months the composite of death, heart failure events or upgrade to biventricular pacing occurred in 2.4 against 12.5 per cent (hazard ratio 0.37, 95 per cent CI 0.19 to 0.73), driven by heart failure events (3.4 against 11.3 per cent); death, upgrade, complications and pacing-induced cardiomyopathy did not differ, and left bundle branch capture was confirmed in 79.7 per cent.
What it means for the exam. One randomised trial now supports left bundle branch area pacing over a right ventricular lead in this group. ESC 2021 gives His bundle pacing only a class IIb recommendation and says nothing about left bundle branch area pacing; the 2023 HRS, APHRS and LAHRS physiologic pacing guideline addresses conduction system pacing; there is no Australian pacing guideline. Cite the trial with its limits (14 Chinese hospitals, a composite driven by heart failure events) and the guideline position beside it. Do not say it reduced mortality.
Also published in October
The Lancet individual participant data meta-analysis of the five randomised trials of 0/1 h against 0/3 h troponin pathways (110,933 presentations, 29 October 2026) found low 30 day event rates on both pathways (0.8 against 1.0 per cent, an imprecise pooled estimate) and, on average, no shorter emergency department stay (314 against 308 minutes) and no clear gain in direct discharge (67.0 against 65.8 per cent). The pathway's throughput benefit depends on the system around it.
Left out, and why
The TGA's notice on avacopan could not be opened at its source this week (tga.gov.au returned 503 on every attempt), so it is not here; the vasculitis courses carry the drug's status from other sources. The other October trials (IgA nephropathy APRIL inhibitors, MILD-MT and LATE-MT, REMODEL, DeLLphi-305 and others) are abstracts only and are in the landmark trials courses where they change teaching.
How to use this
Each item above is already in the Physify courses it touches, with the change logged and dated. The companion page at /guideline-updates/2026-10 carries the same items in short form, and the courses, 352 of them, with 11,100+ questions, are where the detail and the practice live. Next month's post will follow the same shape.