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Therapeutic Guidelines (eTG) and the AMC Exam: What IMGs Need to Know
Last reviewed: May 2026 | Written by the MplusX Editorial Team
📌 Key Takeaways
- The Therapeutic Guidelines (eTG) is the absolute reference for all pharmacology and prescribing questions on the AMC MCQ.
– International guidelines (such as US or UK protocols) often conflict with Australian eTG rules on antibiotic selection, asthma management, and chronic disease pathways.
– High-yield topics include community-acquired pneumonia (CAP) grading, COPD exacerbation oxygen targets (88–92%), HFrEF SGLT2 inhibitor updates, and diabetic renal dose adjustments.
– Primary CTA: Start your 1-week MplusX trial — access our 5,500+ question bank built entirely on live eTG clinical standards with detailed citations.
It is one of the most frustrating moments in AMC MCQ preparation.
You read a clinical vignette about a patient with mild, cough-variant chest symptoms. You diagnose mild community-acquired pneumonia (CAP) correctly. You select oral azithromycin or doxycycline as the initial treatment — just as you did in your home clinic for years, or just as you learned while studying for USMLE.
The screen flashes red.
Incorrect.
The correct option is oral amoxicillin 500mg three times daily (TDS) for 5 days.
Under the Australian Therapeutic Guidelines (eTG), prescribing azithromycin or doxycycline for mild CAP without a documented penicillin allergy is considered a clinical error. In the eyes of the AMC examiners, it represents a failure to practice safe, guideline-aligned medicine.
To pass the AMC MCQ, you must set aside your home country’s prescribing habits and align your clinical decisions with the eTG. This guide breaks down the essential eTG rules you must master to secure these high-yield pharmacology marks.
What Is the eTG and Why Does the AMC Care?
The Therapeutic Guidelines (eTG) is Australia’s independent, evidence-based authority on pharmacotherapy. Updated continuously by expert therapeutic groups, it provides clear, non-commercial advice on drug choice, dosage, route of administration, and treatment duration.
In Australia, irrational prescribing and over-reliance on broad-spectrum antibiotics are treated as major public health issues. Consequently, the AMC MCQ exam heavily tests your adherence to local prescribing guidelines.
The examiners want to verify that you will not:
1. Contribute to antimicrobial resistance by prescribing broad-spectrum antibiotics when narrow-spectrum options are first-line.
2. Prescribe contraindicated medications in patients with chronic organ impairment (e.g., prescribing metformin in severe renal failure).
3. Ignore recent updates to cardiovascular or metabolic guidelines (e.g., failing to prescribe SGLT2 inhibitors for heart failure).
Every prescribing decision in the AMC syllabus is pulled directly from the active eTG database. If your study bank or textbooks are not aligned with the current eTG, you are preparing to fail.
The Prescribing Discrepancy: Australian Rules vs. International Practice
Many international medical graduates struggle with the AMC pharmacology questions because they rely on international guidelines like NICE (UK) or ACC/AHA (US). While the clinical principles are similar, the specific drug choices and thresholds differ.
Here are the most significant discrepancies you must watch out for:
1. Antibiotic Stewardship (Infectious Diseases)
Australia has one of the strictest antibiotic stewardship programs in the world. Narrow-spectrum drugs are strongly preferred for initial therapy.
CAP[“Patient with Suspected CAP”] –> Severity{“Assess Clinical Severity”}
Severity –>|Mild: CURB-65 0-1| Mild[“Mild CAP – Outpatient
Amoxicillin 500mg TDS oral × 5 days”]
Severity –>|Moderate: CURB-65 2| Mod[“Moderate CAP – Inpatient
Benzylpenicillin 1.2g IV 6-hourly + Doxycycline 100mg BD oral”]
Severity –>|Severe: CURB-65 >=3| Sev[“Severe CAP – ICU / High Dependency
Piperacillin-Tazobactam 4.5g IV 6-hourly + Azithromycin 500mg IV daily”]
style CAP fill:#0F2D5C,stroke:#fff,color:#fff
style Severity fill:#D69E2E,stroke:#fff,color:#fff
style Mild fill:#166534,stroke:#fff,color:#fff
style Mod fill:#2A7D7B,stroke:#fff,color:#fff
style Sev fill:#991B1B,stroke:#fff,color:#fff
If a question specifies that the patient has a non-severe hypersensitivity to penicillin (e.g., a mild rash, but no anaphylaxis), the eTG antibiotic alternative for mild CAP is doxycycline 100mg twice daily (BD) for 5 days. If the patient has a severe hypersensitivity to penicillin (e.g., anaphylaxis, angioedema), the correct choice is doxycycline or roxithromycin.
The eTG Master Prescribing Reference Table
Use this master reference table to memorize the high-yield first-line regimens and penicillin allergy alternatives tested on the AMC MCQ:
| Clinical Condition | Severity / Classification | First-Line eTG Regimen (Dose & Duration) | Alternative for Mild Penicillin Allergy (Rash) | Alternative for Severe Penicillin Allergy (Anaphylaxis) |
|---|---|---|---|---|
| Community-Acquired Pneumonia (CAP) | Mild (Outpatient) | Amoxicillin 500mg TDS oral for 5 days | Doxycycline 100mg BD oral for 5 days | Doxycycline 100mg BD OR Roxithromycin 300mg daily |
| Community-Acquired Pneumonia (CAP) | Moderate (Inpatient Ward) | Benzylpenicillin 1.2g IV 6-hourly + Doxycycline 100mg BD oral | Ceftriaxone 1–2g IV daily + Doxycycline 100mg BD oral | Doxycycline 100mg BD oral + Moxifloxacin 400mg daily IV/oral |
| Community-Acquired Pneumonia (CAP) | Severe (ICU / HDU) | Piperacillin-Tazobactam 4.5g IV 6-hourly + Azithromycin 500mg IV daily | Ceftriaxone 2g IV daily + Azithromycin 500mg IV daily | Moxifloxacin 400mg IV daily + Aztreonam 2g IV 8-hourly |
| Acute Uncomplicated Cystitis (UTI) | Female, non-pregnant | Trimethoprim 300mg daily oral for 3 days OR Nitrofurantoin 100mg BD oral for 5 days | Cephalexin 500mg BD oral for 5 days | Nitrofurantoin 100mg BD oral for 5 days OR Trimethoprim 300mg daily |
| Acute Pyelonephritis | Uncomplicated, mild/moderate | Gentamicin 4–6mg/kg IV daily + Ampicillin 2g IV 6-hourly | Ceftriaxone 1–2g IV daily | Gentamicin 4–6mg/kg IV daily + Ciprofloxacin 400mg IV 12-hourly |
| Acute Cellulitis | Non-purulent (limb) | Flucloxacillin 500mg to 1g QID oral for 5 to 10 days | Cephalexin 500mg to 1g QID oral for 5 to 10 days | Clindamycin 300mg to 450mg TDS oral for 5 to 10 days |
| Acute Cellulitis | Purulent / MRSA Suspected | Trimethoprim-Sulfamethoxazole 160/800mg BD oral | Trimethoprim-Sulfamethoxazole 160/800mg BD oral | Clindamycin 300mg to 450mg TDS oral |
| Acute Otitis Media | Paediatric (systemic illness/high-risk) | Amoxicillin 15mg/kg (up to 500mg) TDS oral for 5 days | Cephalexin 25mg/kg (up to 1g) BD oral | Trimethoprim-Sulfamethoxazole 4/20mg/kg (up to 160/800mg) BD oral |
| Acute Streptococcal Tonsillitis | Centor Criteria Met / High Risk | Phenoxymethylpenicillin 500mg BD oral for 10 days | Cephalexin 500mg BD oral for 10 days | Erythromycin 250mg QID oral for 10 days |
| Acute Meningitis | Adult, Community-Acquired | Ceftriaxone 2g IV 12-hourly + Benzylpenicillin 2.4g IV 4-hourly (if Listeria risk, e.g., >50yo) | Ceftriaxone 2g IV 12-hourly + Trimethoprim-Sulfamethoxazole 5mg/kg (trimethoprim component) IV 6-hourly | Meropenem 2g IV 8-hourly + Moxifloxacin 400mg IV daily |
| Anaphylaxis | Emergency Presentation | Adrenaline 1:1000 0.5mg IM into anterolateral thigh | N/A (Life-threatening emergency) | N/A (Life-threatening emergency) |
| Helicobacter pylori Eradication | Confirmed infection (active) | Esomeprazole 20mg BD + Amoxicillin 1g BD + Clarithromycin 500mg BD for 7 days | Esomeprazole 20mg BD + Metronidazole 400mg BD + Clarithromycin 500mg BD for 7 days | Esomeprazole 20mg BD + Metronidazole 400mg BD + Clarithromycin 500mg BD for 7 days |
| Acute Gout Flare | Initial management | Colchicine 500mcg oral, then 500mcg after 1 hour (max 1mg in 24 hours) OR Indomethacin 50mg TDS oral | N/A | N/A |
| Mild Asthma Exacerbation | Paediatric / Adult | Salbutamol 4 to 12 puffs via spacer every 20 mins for 1 hour + Prednisolone 1mg/kg (up to 50mg) oral | N/A | N/A |
| Chlamydia trachomatis Urethritis | Confirmed sexually transmitted | Doxycycline 100mg BD oral for 7 days (first-line) | N/A | N/A (Azithromycin 1g oral single dose is second-line due to resistance) |
Differentiating Penicillin Allergies: Severe vs. Non-Severe
A major source of error for candidates is the misinterpretation of “penicillin allergy” in clinical vignettes. If a patient reports a penicillin allergy, many IMGs immediately rule out all beta-lactam antibiotics. Under eTG, this is an incorrect practice. You must stratify the allergy:
Severe Hypersensitivity (IgE-Mediated Immediate Reaction)
* Definition: Anaphylaxis, angioedema, bronchospasm, cardiovascular collapse, or immediate urticarial rash occurring within 1 to 2 hours of drug administration. * Cross-Reactivity Risk: High cross-reactivity risk with other beta-lactams. Cephalosporins (especially 1st generation like cephalexin) are contraindicated. * eTG Action: Avoid all penicillins, carbapenems, and cephalosporins. Select non-beta-lactam alternatives (e.g., doxycycline, macrolides, quinolones, or clindamycin).Non-Severe Hypersensitivity (T-Cell Mediated Delayed Reaction)
* Definition: Maculopapular, morbilliform, or pruritic skin rash appearing more than 72 hours after commencing therapy, without systemic symptoms (no mucosal involvement, eosinophilia, or joint pain). * Cross-Reactivity Risk: Low cross-reactivity risk with cephalosporins (<1%). * eTG Action: Penicillins should be avoided, but cephalosporins (specifically cephalexin or ceftriaxone) are considered safe first-line options.5 High-Yield eTG Prescribing Rules for the AMC MCQ
To secure high-yield pharmacology marks, you should memorize these five core rules from the eTG:
Rule 1: SGLT2 Inhibitors Are Now Standard of Care for Heart Failure (HFrEF)
In HFrEF (EF <40%), the modern therapeutic strategy is built around the "four pillars" of treatment. You do not wait to initiate these drugs sequentially. Instead, you start them as early as possible:
1. ACE Inhibitor, ARB, or ARNI (sacubitril-valsartan)
2. Beta-blocker (carvedilol, bisoprolol, or metoprolol succinate)
3. MRA (spironolactone or eplerenone)
4. SGLT2 Inhibitor (empagliflozin or dapagliflozin)
The addition of SGLT2 inhibitors is a recent change that is heavily tested. If an AMC question asks for the optimal drug regimen for a patient with symptomatic heart failure who is already on ramipril and bisoprolol, the correct answer will involve adding empagliflozin or spironolactone.
When monitoring these therapies:
* Assess serum potassium and renal function (eGFR) 1 to 2 weeks after initiating an ACEi/ARB or MRA. * Do not initiate an MRA if potassium is >5.0 mmol/L or eGFR is <30 mL/min/1.73m².Rule 2: COPD Oxygen Targets Must Be Domiciled Between 88% and 92%
In patients with chronic obstructive pulmonary disease (COPD) experiencing an acute exacerbation, administering high-flow oxygen to achieve a normal saturation (>95%) is dangerous.
It suppresses their hypoxic respiratory drive, leading to carbon dioxide retention, respiratory acidosis, and death. eTG mandates a controlled oxygen target of 88% to 92% via a Venturi mask or nasal cannulae.
Rule 3: Metformin Contraindications in Renal Impairment
Metformin is cleared renally and can cause fatal lactic acidosis in patients with significant renal impairment.
- eGFR 30–45 mL/min: Use metformin with caution; consider a maximum dose of 1,000mg daily.
- eGFR <30 mL/min: Metformin is contraindicated and must be stopped immediately.
Other oral hypoglycaemics are adjusted as follows in renal impairment:
* SGLT2 inhibitors (empagliflozin/dapagliflozin): Do not initiate for glycemic control if eGFR <30 mL/min. However, if already tolerated, they may be continued down to eGFR 15-20 mL/min for cardiovascular or renal protective benefits. * DPP-4 inhibitors: Linagliptin requires no renal dosage adjustment (excreted via bile). Sitagliptin must be reduced to 25mg daily if eGFR <30 mL/min. * GLP-1 receptor agonists (semaglutide/dulaglutide): Can be used down to eGFR 15 mL/min.Renal[“eGFR Thresholds for Diabetes Meds”] –> E30[“eGFR < 30"]
Renal –> E45[“eGFR 30–45”]
Renal –> E60[“eGFR >= 45”]
E30 –> Met30[“Cease Metformin immediately
Lactic acidosis risk”]
E30 –> SGLT30[“Avoid initiating SGLT2i
Consider alternate therapies”]
E45 –> Met45[“Reduce Metformin dose
Max 1,000mg daily”]
E45 –> SGLT45[“Continue SGLT2i if tolerated
Avoid new initiations”]
E60 –> Safe[“Metformin and SGLT2i safe
Standard dosing applies”]
style E30 fill:#991B1B,stroke:#fff,color:#fff
style E45 fill:#D69E2E,stroke:#fff,color:#fff
style E60 fill:#166534,stroke:#fff,color:#fff
Rule 4: Acute Asthma Management Steps
For a patient presenting with an acute asthma exacerbation, the eTG outlines a strict step-up sequence:
1. Mild to Moderate: Salbutamol (SABA) via spacer (4 to 12 puffs, every 20 minutes for the first hour) + oral prednisolone (1mg/kg up to 50mg).
2. Severe: Oxygen (target SpO2 93–95%) + continuous nebulised salbutamol + ipratropium bromide (SAMA) + IV hydrocortisone or oral prednisolone.
3. Life-threatening: Immediate ICU consultation + IV magnesium sulphate (single dose of 1.2 to 2g IV over 20 minutes) + IV aminophylline or salbutamol.
Rule 5: Eradication of Helicobacter pylori
The first-line eradication protocol under the eTG is a triple-therapy regimen:
- Esomeprazole 20mg (or equivalent PPI) twice daily (BD)
- Amoxicillin 1g twice daily (BD)
- Clarithromycin 500mg twice daily (BD)
- Duration: 7 days
If the patient has a confirmed penicillin allergy, amoxicillin is replaced with metronidazole 400mg twice daily. The test of cure must be performed using a urea breath test at least 4 weeks after the completion of therapy (and at least 2 weeks after stopping PPIs). Serological testing is never used as a test of cure.
How to Integrate eTG into Your Study Routine
You do not need to purchase a personal subscription to the eTG to pass the AMC MCQ.
If you are currently working in an Australian hospital or clinic, you will have free access through your institution’s library portal or state health network. If you are preparing from offshore, you can utilize the detailed citations in MplusX QBank explanations, which quote the relevant eTG sections.
Here is how to build your eTG knowledge systematically:
1. Keep a Pharmacology Logbook: Dedicated to prescribing rules. Every time you get a pharmacology question wrong, write down: the diagnosis, the first-line drug, the dose, the duration, and the penicillin-allergy alternative.
2. Focus on Transitions of Care: The AMC loves to test what happens when a patient is discharged from hospital. For example, when a patient is discharged after a STEMI, what secondary prevention medications must they be taking? (Answer: Aspirin + P2Y12 inhibitor for 12 months, a beta-blocker, an ACE inhibitor, and a high-dose statin).
3. Watch the Pregnancy Classifications: Pay attention to drugs that are contraindicated in pregnancy (Category X or D), such as ACE inhibitors (fetal renal dysgenesis), sodium valproate (neural tube defects), and statins.
Frequently Asked Questions
What is the most high-yield eTG chapter for the AMC MCQ?
The Antibiotic Guidelines (Infectious Diseases) is the highest-yield chapter. You can expect multiple questions testing your selection of antibiotics for pneumonia, urinary tract infections (UTIs), skin infections (cellulitis vs. erysipelas), and meningitis. The Cardiovascular Guidelines (heart failure, hypertension, ACS) is a close second.Can I use US guidelines (AHA/ADA) instead of the eTG?
No. Using US guidelines will cause you to select incorrect drug choices on the AMC MCQ. For example, US guidelines often recommend macrolides (like azithromycin) as first-line therapy for mild community pneumonia, whereas Australian guidelines mandate narrow-spectrum amoxicillin. Always defer to the eTG.How are penicillin allergies classified under the eTG?
eTG divides penicillin allergies into:
- Immediate hypersensitivity (severe): Anaphylaxis, bronchospasm, angioedema, or urticaria occurring within 1 to 2 hours of drug administration. Penicillins and cephalosporins must be avoided.
- Delayed hypersensitivity (mild/non-severe): Maculopapular rash appearing after 72 hours. Cephalosporins (like cephalexin) can often be used with caution, or doxycycline/macrolides are selected depending on the infection.
Is the eTG updated during the year?
Yes. The digital version of the Therapeutic Guidelines (eTG) is updated multiple times a year as new clinical trial data emerges. The MplusX QBank editors review these updates weekly to ensure our question bank reflects the live guidelines that examiners use to score the exam.What SGLT2 inhibitor precautions should I know for major surgery?
Under active eTG guidelines, SGLT2 inhibitors (empagliflozin, dapagliflozin) must be withheld 2 to 3 days prior to major surgery or procedures requiring bowel preparation. This minimizes the severe risk of perioperative euglycemic diabetic ketoacidosis (DKA). Restart therapy only once the patient is eating and drinking normally with stable renal function.How do we manage primary dysmenorrhoea under eTG rules?
First-line pharmacological therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid (500mg TDS) or ibuprofen (400mg TDS) initiated at the onset of bleeding or pain. If NSAIDs are contraindicated or ineffective, transition to the combined oral contraceptive pill (COCP) or a progestogen-only intrauterine system (Mirena).Written by the MplusX Editorial Team — dedicated to providing clinically accurate, structured, and practical resources for international medical graduates pursuing licensing with the Australian Medical Council.
References
- Therapeutic Guidelines (eTG): Antibiotic Guidelines; Cardiovascular Guidelines; Respiratory Guidelines; Clinical Prescribing Principles.
- John Murtagh’s General Practice (8th Edition): Chapter 10: Clinical masquerades; Chapter 12: Prescribing in general practice.
- RACGP Red Book (10th edition): Chapter 8: Prevention of vascular and metabolic disease.
Disclaimer: This article is written for AMC MCQ examination preparation and general informational purposes only. It does not constitute medical advice, diagnosis, or treatment recommendations. Clinical decisions should always be based on individual patient assessment, current Australian Therapeutic Guidelines (eTG), and consultation with qualified healthcare professionals. MplusX is an exam preparation platform and is not a substitute for supervised clinical training.