Victoria’s chief health officer has flagged 13 anaphylaxis cases related to unapproved peptide drugs since July 2025, at least one of which was fatal.
Federal MP Dr Monique Ryan has revived her call for a parliamentary inquiry into online-only telehealth clinics, after a Victorian coroner linked a death from anaphylaxis to the use of unapproved peptides.
Melbourne-based martial artist and actor Richard Norton died on 30 March 2025 at the Alfred Hospital from anaphylaxis and complications of an out-of-hospital cardiac arrest, as well as asthma and hypertrophic cardiomyopathy.
Mr Norton was 75 years of age and had been prescribed CJC1295 & Ipamorelin, an injectable peptide therapy, for symptoms related to fatigue, reduced physical recovery, shoulder pain and loss of lean muscle mass.
In findings published on Wednesday, Victorian coroner David Ryan concluded that Mr Norton’s death was triggered by the injection of an unapproved peptide medication in excess of the dose prescribed by his medical practitioner.
The prescribing doctor had completed blood tests and a CT artery calcium score prior to prescribing the medicine off-label, which was made by a licensed compounding pharmacy in Queensland.
Mr Norton had signed an informed consent form which acknowledged anaphylaxis as a risk.
Earlier this week, Victorian chief health officer Dr Caroline McElnay released new guidance on anaphylaxis and unapproved peptides.
She noted that there had been 13 cases of anaphylaxis associated with unapproved peptide use in July 2025, including five cases in September alone.
All bar one patient had never experienced anaphylaxis prior.
Some patients only experienced anaphylaxis after taking several doses uneventfully.
Dr McElnay advised health practitioners to continue to notify the Victorian Department of Health using the anaphylaxis notification form and noting down any potential link to unapproved peptides.
“Clinicians are encouraged to have open, non-judgemental discussions with patients about the use of unapproved peptides and assist them to working towards their health goals in a safe sustainable manner,” Dr McElnay said.
“Advise patients of the very real risk of anaphylaxis and the need for immediate care if symptoms develop.
“The TGA has requested health professionals report adverse effects related to unapproved peptides.”
The coroner concluded his findings by recommending that the TGA review unapproved peptides consider whether further restrictions should be imposed their use.
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Dr Ryan, a paediatric neurologist and the independent member for Kooyong, said her thoughts were with Mr Norton’s family and that his death “should be a turning point”.
She argued that the TGA could act immediately on the coroner’s recommendation, and also referenced health minister Mark Butler’s 2024 decision to ban GLP-1 RA compounding.
“Influencers are selling these products to young Australians, particularly young men struggling with their body image,” Dr Ryan said.
“I wrote to the Health Minister in August asking him to refer telehealth and online prescribing to the House Health Committee.
“Since then a coroner has confirmed a death, and the harm keeps growing. Telehealth has transformed access to care, particularly for rural patients, women and people who can’t easily see a doctor in person.
“But there are concerns about commercially driven telehealth models, and the unregulated prescribing of some medications. This inquiry is about protecting good telehealth from profit-driven prescribing, not winding it back.”
To be clear, there was no mention of telehealth in the coroner’s report on Mr Norton’s death.
Alongside telehealth business models, Dr Ryan’s proposed inquiry would examine gaps in the regulation and oversight of prescribing for medicines with high potential for misuse, as well as the pathways that allow unapproved peptides to be prescribed and compounded.
“The TGA approves medicines and AHPRA oversees doctors, but no one has responsibility for the corporate structures and commercial incentives that now drive much of online prescribing,” Dr Ryan told The Medical Republic.
“We need to consider some form of oversight of online health providers – by licensing or regulation. The UK does this through the Care Quality Commission.
“We must look at separating prescribing from dispensing and retail – to remove conflict of interest concerns. And we need sufficient visibility of prescribing patterns, particularly for unapproved and compounded products.”
