REALM – Decision and change summary
Medicines endorsed for inclusion in the REALM
| Medicine name | Formulation | REALM Indication | Date |
| Baloxavir (Xofluza®) influenza | Tablet | Severe oseltamivir-resistant influenza | July 2026 |
| Diphtheria antitoxin | Vial | Diphtheria | July 2026 |
| Favipiravir | Tablet | Andes hantavirus or severe fever with thrombocytopenia syndrome or ebolavirus postexposure prophylaxis | July 2026 |
| Hendra virus monoclonal antibody | Vial | Hendra or nipah virus post-exposure prophylaxis | July 2026 |
| Ribavirin (Ibavyr®) | Tablet | Lassa fever or Crimean-Congo haemorrhagic fever or South American viral haemorrhagic fevers | July 2026 |
| Smallpox vaccine (ACAM2000®) | Vial | Mpox or smallpox vaccination | July 2026 |
| Tecovirimat | Vial | Mpox or smallpox vaccination | July 2026 |
| Trifluridine | Eye drop | Ocular mpox or smallpox | July 2026 |
| Vaccinia immunoglobulin | Vial | Mpox or smallpox or vaccine complication | July 2026 |
| Alprostadil | Ampoule | Maintenance of ductus arteriosus patency in neonates | March 2026 |
| Ascorbic acid (Vitamin C) | Vial | Treatment of methaemoglobinaemia | March 2026 |
| Benzatropine | Vial | Treatment of acute dystonia in antipsychotic poisoning | March 2026 |
| Botulism antitoxin (BAT®) | Vial | Treatment of botulism in adults and children (1 year and above) | March 2026 |
| Botulism immunoglobulin (BabyBIG®) | Vial | Treatment of botulism in infants (<1 year) | March 2026 |
| Bromocriptine | Vial | Treatment of neuroleptic malignant syndrome (NMS) | March 2026 |
| Calcium trisodium pentetate (Ca-DTPA) | Ampoule | Decorporation of transuranium heavy metal radionuclides (americium, plutonium, curium, californium, berkelium) | March 2026 |
| Dantrolene | Ampoule | Treatment of malignant hyperthermia | March 2026 |
| Flumazenil | Ampoule | Treatment of benzodiazepine poisoning | March 2026 |
| Folic acid | Vial | Folate supplementation for methanol poisoning | March 2026 |
| Folinic acid (as calcium folinate) | Tablet | Folate supplementation for methanol poisoning or treatment of methotrexate poisoning | March 2026 |
| Lipid emulsion | Injection bag/bottle | Severe local anaesthetic toxicity | March 2026 |
| Naloxone | Ampoule, pre-filled syringe | Reversal of central nervous system and respiratory depression caused by opioid intoxication | March 2026 |
| Phentolamine | Ampoule/vial | Treatment of extravasation of adrenaline (epinephrine), noradrenaline (norepinephrine), dobutamine, or dopamine | March 2026 |
| Phytomenadione (Vitamin K1) | Ampoules, capsule | Excessive anticoagulation with warfarin or superwarfarin (rodenticides) | March 2026 |
| Prussian blue | Capsule | Decorporation of radioactive caesium and/or radioactive or non-radioactive thallium | March 2026 |
| Rasburicase | Vial | Acute hyperuricaemia associated with tumour lysis in haematological malignancy | March 2026 |
| Rivastigmine | Capsules, patches | Antimuscarinic (anticholinergic) delirium | March 2026 |
| Tocilizumab | Vial | Chimeric antigen receptor (CAR) T cell-induced cytokine release syndrome | March 2026 |
Medicines endorsed for removal from the REALM
| Medicine | Reason for removal | Date |
| Black snake antivenom; Death adder antivenom; Taipan antivenom | Black snake, death adder, and taipan monovalent antivenoms are not recommended for use in the NSW Health Snake and Spider Bites Clinical Management Guideline (GL2024_007). Polyvalent snake antivenom (listed in the REALM) contains antibodies to five snake groups: black snake, taipan, death adder, tiger snake and brown snake. This antivenom covers most of the clinically important snake groups in Australia and Papua New Guinea. All NSW hospitals with the intention of treating snake bites are recommended to stock at least 1 vial of polyvalent snake antivenom per GL2024_007. | March 2026 |
| Dimercaprol | Dimercaptopropane-1-sulfonate (DMPS) is first-line treatment for lead or arsenic (acute) poisoning. Dimercaprol may be used as a second-line alternative in combination with edetate calcium disodium (EDTA) (listed in the REALM). EDTA can also be used as a single agent if other parenteral chelating agents are unavailable. | March 2026 |
| Redback spider antivenom | Redback spider antivenom is not recommended for use in the NSW Health Snake and Spider Bites Clinical Management Guideline (GL2024_007). Redback spider envenomation is not life-threatening, and evidence shows that antivenom administration does not change patient outcomes | March 2026 |
| Test agent multiple snake antivenom | Snake venom detection kits are not recommended for use in the NSW Health Snake and Spider Bites Clinical Management Guideline (GL2024_007). Testing is associated with higher rates of false positive results, primarily due to operator error | March 2026 |
Change requests not endorsed for listing on the REALM
| Medicine | Indication | Reason for not listing | Date |
| Andexanet alfa vial | Reversal of anticoagulation (apixaban or rivaroxaban) when needed due to life threatening or uncontrolled bleeding. | The CEC NSW Medicines Formulary Committee has reviewed the available safety evidence following the recent US FDA Safety Communication. Current evidence indicates an increased risk of thrombosis without clear evidence of improved clinical outcomes in patients with acute major bleeding, including intracerebral haemorrhage (ICH). While andexanet alfa remains provisionally registered in Australia, it is not listed on the NSW Medicines Formulary and the associated Formulary Information has been updated to reflect these safety considerations. | March 2026 |
| Brivaracetam vial | For seizure control when levetiracetam is not tolerated or contraindicated. | Brivaracetam vial is not recommended as a first-line agent for the management of status epilepticus. Established first-line therapy (benzodiazepines) and alternative second-line antiepileptics (such as levetiracetam or sodium valproate) are widely available and indicated for management. | March 2026 |
Change requests currently under consideration
There are no change requests currently under consideration.