Acute Pain in Older People

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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Older adults (≥65 years) frequently under-report or mask acute pain due to stoicism, fear of hospitalisation, or belief that pain is a normal part of ageing — always use validated observational tools in addition to self-report scales.
Atypical pain presentations are common: acute coronary syndrome may present as dyspnoea or confusion rather than chest pain; intra-abdominal catastrophe may present as restlessness alone.
Cognitive impairment (dementia, delirium) does not mean the patient cannot experience pain — use behavioural observation tools such as PAINAD, Abbey, or ABBEY scale to assess pain.
Pharmacokinetic changes in ageing (reduced renal clearance, increased body fat, decreased serum albumin) result in prolonged half-lives for opioids and NSAIDs — start low, go slow.
Paracetamol (≤2 g/day in frail elderly or those <50 kg) remains first-line; avoid routine use of codeine due to unpredictable CYP2D6 metabolism and risk of constipation, falls, and respiratory depression.
Opioid sensitivity increases with age: initial opioid doses should be reduced by 25–50% compared with younger adults, with extended titration intervals (e.g., oxycodone 2.5 mg every 6–8 hours).
NSAIDs carry significantly higher risk in older adults (GI bleeding, acute kidney injury, cardiovascular events) and should be avoided or used at the lowest dose for the shortest duration possible.
Polypharmacy is the norm in older patients — check for drug interactions before prescribing analgesics, particularly with anticoagulants, antihypertensives, SSRIs, and other sedating agents.
Non-pharmacological strategies (ice, positioning, distraction, music therapy) are evidence-based adjuncts that should be offered to every older patient.
Regular reassessment is critical: older people may develop delirium, falls, or respiratory depression from analgesics — use the RASS and 4AT to monitor for adverse effects.
Opioid analgesics should be reviewed within 24–48 hours with an exit plan; long-term continuation requires documented indication, clear benefit, and safety monitoring.
Aboriginal and Torres Strait Islander older adults may experience barriers to pain assessment and access to analgesics; culturally appropriate tools and multidisciplinary engagement are essential.

Introduction & Australian Epidemiology

Acute pain in older adults (≥65 years) represents a significant clinical challenge in Australian healthcare. Pain is the most common reason for emergency department (ED) presentations in this age group, yet it remains consistently undertreated. The Australian Institute of Health and Welfare (AIHW) estimates that approximately 60–80% of residential aged care residents experience pain, with acute pain superimposed on chronic conditions in many cases.

Several factors contribute to the under-recognition and undertreatment of acute pain in older Australians:

Age-related physiological changes alter pain perception, pharmacokinetics, and pharmacodynamics.
Prevalence of cognitive impairment — approximately 30% of people aged ≥75 have some degree of dementia — limits the utility of standard verbal pain scales.
Polypharmacy (defined as ≥5 regular medications) affects over 60% of Australians aged ≥75, creating complex drug interactions with analgesic agents.
Atypical disease presentations mean that serious pathology may present without classic pain features.
The ageing Australian population (projected 22% aged ≥65 by 2056) makes this an increasingly urgent public health issue.

This guideline provides a framework for the safe and effective management of acute pain in older people across Australian acute and primary care settings, with emphasis on atypical presentations, cognitive impairment, opioid sensitivity, and polypharmacy considerations.

Atypical Pain Presentations

Older adults frequently present with atypical pain syndromes that differ markedly from classical descriptions. Failure to recognise atypical presentations is a leading cause of delayed diagnosis and increased morbidity in Australian hospitals.

Common Atypical Patterns

Condition	Classical Presentation	Atypical Presentation in Older Adults	Red Flags
Acute coronary syndrome	Central crushing chest pain radiating to left arm	Dyspnoea, fatigue, nausea, confusion, syncope, or epigastric discomfort	New confusion, unexplained hypotension, diaphoresis
Acute abdomen	Severe localised abdominal pain, guarding	Anorexia, restlessness, vague discomfort, malaise, mild distension	Absent or minimal abdominal signs despite serious pathology; raised lactate
Fracture (hip, vertebral)	Acute localised pain after fall or trauma	Refusal to weight-bear, new immobility, groin or knee pain, subtle postural change	New inability to stand; low-energy fracture mechanism
Herpes zoster	Dermatomal vesicular rash with burning pain	Prodromal pain preceding rash by 3–5 days; may be mistaken for musculoskeletal pain	Dermatomal distribution, skin hyperaesthesia
Urinary retention	Suprapubic pain, inability to void	Agitation, confusion, restlessness, behavioural disturbance without overt pain complaint	Palpable bladder; overflow incontinence
Mesenteric ischaemia	Severe periumbilical pain "out of proportion to examination"	Subtle abdominal discomfort, metabolic acidosis, bloating, diarrhoea	Atrial fibrillation, lactic acidosis, raised WCC

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Clinical Pearl: In older adults, the absence of pain does not exclude serious pathology. A high index of clinical suspicion, low threshold for investigation, and regular reassessment are essential. Always consider the full differential when an older person presents with non-specific symptoms such as confusion, falls, or functional decline.

Why Older People Under-Report Pain

Generational stoicism: Many older Australians were raised to "soldier on" and may not volunteer information about pain.
Fear of consequences: Concern that reporting pain will lead to hospital admission, loss of independence, or nursing home placement.
Normalisation of pain: Belief that pain is an inevitable consequence of ageing that must be tolerated.
Communication barriers: Hearing impairment, aphasia (post-stroke), English as a second language, or culturally different pain expression patterns.
Cognitive impairment: Inability to recall, localise, or describe pain experiences.
Health literacy: Limited understanding of analgesic options or how to describe symptoms effectively.

Pain Assessment in Cognitive Impairment

Approximately 50% of people living in Australian residential aged care facilities have dementia. Cognitive impairment does not abolish pain perception — the evidence confirms that people with dementia experience pain equally to those without. However, impaired communication makes assessment challenging and requires systematic approaches.

Tiered Assessment Approach

Self-Report (Mild Impairment)

Use simple verbal descriptor scales (no pain / mild / moderate / severe), visual analogue scales, or the Faces Pain Scale. Ask directly: "Are you in pain?" Check comprehension first. Repeat at rest and with movement.

Observational Tools (Moderate–Severe Impairment)

When self-report is unreliable, use validated behavioural observation scales. Recommended Australian tools include:

Trial of Analgesia (Uncertain Cases)

If pain is suspected but cannot be confirmed, a time-limited trial of analgesia (e.g., paracetamol 1 g stat, reassess in 45–60 minutes) with behavioural outcome assessment is appropriate. Response to analgesia supports a pain-related cause.

Validated Observational Pain Scales for Cognitively Impaired Older Adults

Scale	Population	Domains Assessed	Score Range	Availability in Australia
PAINAD (Pain Assessment in Advanced Dementia)	Severe dementia	Breathing, negative vocalisation, facial expression, body language, consolability	0–10	Widely used in RACFs; free to access
Abbey Pain Scale	Non-verbal older adults (dementia, post-stroke)	Vocalisation, facial expression, change in body language, behavioural change, physiological change, physical change	0–24 (mild/moderate/severe)	Standard in Australian RACFs; endorsed by PainChek®
APPT (Abe Assessment of Pain in People with Impaired Cognition)	Various cognitive levels	Behavioural indicators during care activities	0–10	Used in some Australian geriatric services
PainChek®	Non-verbal / cognitively impaired	AI-assisted facial micro-expression analysis + 6 domains	0–14 (no pain) to >14 (pain)	TGA-approved digital health tool; validated in Australian RACFs
FLACC (Face, Legs, Activity, Cry, Consolability)	Originally paediatric; adapted for non-verbal adults	Facial expression, leg movement, activity, cry, consolability	0–10	Available; used in acute care for non-verbal older adults

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Safety Alert: Never assume that a patient with dementia "doesn't feel pain." Undertreated pain in cognitively impaired older adults leads to agitation, behavioural disturbances (often misattributed to "behavioural and psychological symptoms of dementia" — BPSD), falls, delirium, and reduced quality of life. A trial of analgesia should precede antipsychotic prescription when agitation is the presenting feature.

Distinguishing Pain from Delirium

Pain and delirium frequently coexist and overlap in presentation. Use the 4AT (rapid assessment test for delirium) alongside a behavioural pain scale. Key distinguishing features:

Feature	Pain	Delirium
Onset	May correlate with movement, position change, procedure	Acute, fluctuating; often worse at night (sundowning)
Attention	Generally preserved between painful episodes	Impaired; difficulty sustaining or shifting attention
Behaviour	Guarding, grimacing, withdrawal from stimulus	Agitation, pulling at lines, disorganised thinking
Response to analgesia	Improvement in behaviour with appropriate analgesia	No improvement or worsening with opioids (may worsen delirium)

Opioid Sensitivity in Older Adults

Older adults demonstrate increased sensitivity to opioid analgesics due to age-related pharmacokinetic and pharmacodynamic changes. This has profound implications for prescribing, dosing, monitoring, and safety.

Pharmacological Basis of Opioid Sensitivity

Change	Effect on Opioid Pharmacology	Clinical Consequence
Decreased renal function (GFR decline ~1 mL/min/year after age 40)	Accumulation of active metabolites (morphine-6-glucuronide, morphine-3-glucuronide, norpethidine)	Prolonged sedation, respiratory depression, myoclonus, neurotoxicity
Decreased hepatic mass and blood flow	Reduced Phase I metabolism (CYP-mediated oxidation)	Prolonged half-life of codeine, tramadol, oxycodone
Increased body fat : lean mass ratio	Increased volume of distribution for lipophilic opioids (fentanyl, methadone)	Prolonged duration of action; accumulation with repeated dosing
Decreased serum albumin	Increased free (unbound) drug fraction	Greater effect at equivalent total plasma concentrations
Increased CNS sensitivity (reduced opioid receptor reserve)	Enhanced pharmacodynamic response at lower concentrations	Greater analgesic effect AND greater adverse effect risk per dose
Decreased blood-brain barrier integrity	Increased CNS penetration of opioids	Enhanced sedation and respiratory depression

Principles of Opioid Prescribing in Older Adults

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"Start low, go slow, but titrate to effect." The goal is adequate pain relief — not complete abolition of all pain — with acceptable side effects. Undertreating pain carries its own significant risks (delirium, immobility, respiratory compromise, DVT/PE).

Optimise Non-Opioid Analgesia First

Maximise paracetamol dosing, consider regional/nerve blocks, and use non-pharmacological strategies before initiating opioids.

Select Appropriate Opioid

Short-acting opioids preferred for acute pain. Avoid codeine (unpredictable CYP2D6 metabolism) and tramadol (seizure risk, serotonin syndrome). Morphine or oxycodone remain preferred agents. Hydromorphone is an alternative in renal impairment.

Dose Reduction: 25–50% of Standard Adult Dose

Initial opioid doses should be reduced by at least 25% (ideally 50% in frail or ≥80 years). Example: morphine 2.5–5 mg SC/PO every 4 hours or oxycodone 2.5 mg PO every 6–8 hours.

Extended Titration Intervals

Allow longer intervals between dose adjustments (minimum 48 hours for oral opioids, 24 hours for parenteral) to account for slower equilibration.

Monitor Rigorously

Respiratory rate, sedation score (RASS), oxygen saturation, bowel function, and pain score at defined intervals. Pulse oximetry should be continuous if parenteral opioids are used in hospital.

Review and Exit Plan

All opioid prescriptions should include a planned review date (24–48 hours in hospital; 7 days in community) and a weaning strategy. Long-term continuation requires documented indication.

Drug Cards — Preferred Opioids for Older Adults

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Morphine

Kapanol®, Ms Contin®, Ordine® · Opioid agonist

Adult dose (≥65) 2.5–5 mg PO/SC every 4 hours PRN; reduce to 1.25–2.5 mg if frail or ≥80 years

Route Oral (solution: Ordine®; SR: Kapanol®, Ms Contin®), SC, IV

Renal adjustment eGFR 30–50: reduce dose by 50%, extend interval; eGFR <30: avoid — use hydromorphone

Key adverse effects Constipation (prescribe stool softener), nausea, respiratory depression, delirium, falls

PBS status ✔ PBS General Benefit

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Oxycodone

OxyNorm®, Endone® · Opioid agonist

Adult dose (≥65) 2.5 mg PO every 6–8 hours PRN; titrate to 5 mg after 48 hours if tolerated

Route Oral (immediate-release: Endone®; modified-release: OxyContin®)

Renal adjustment eGFR 30–50: start 1.25–2.5 mg; eGFR <30: avoid — consider hydromorphone

Key adverse effects Similar to morphine; active metabolites accumulate in renal impairment

PBS status ✔ PBS General Benefit

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Hydromorphone

Jurnista®, Dilaudid® · Opioid agonist

Adult dose (≥65) 0.2–0.5 mg PO/SC every 4 hours PRN; titrate cautiously

Renal adjustment Preferred opioid in eGFR <30 mL/min — active metabolites less renally dependent

Key adverse effects Myoclonus at high doses; equianalgesic ratio with morphine is approximately 1:5

PBS status ⚠️ PBS Authority Required

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Fentanyl (transdermal)

Durogesic® · Opioid agonist

Adult dose (≥65) NOT recommended for acute pain in opioid-naive older adults. Reserved for stable chronic pain after opioid tolerance established (minimum 12 µg/hr patch = ~30 mg oral morphine equivalent/day).

Key concern Delayed onset (12–24 hours to peak effect); lipophilic — prolonged duration in obese/elderly; risk of fatal accumulation

PBS status ⚠️ PBS Authority Required

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Codeine is NOT recommended in older adults. CYP2D6 polymorphism leads to ultra-rapid metabolism (risk of toxicity) or poor metabolism (no analgesic effect). The TGA has restricted codeine to prescription-only since 2018. Additionally, codeine's constipating effects are disproportionate in older adults. Tramadol should also be avoided due to seizure risk, serotonin syndrome potential, and complex pharmacogenomics.

Opioid Antagonist Considerations

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Naloxone

Narcan® · Opioid antagonist

Adult dose (rescue) 40–80 micrograms IV every 2–3 minutes; titrate to respiratory effort (avoid full reversal to prevent acute pain and sympathetic crisis). In older adults: start at 20–40 micrograms IV.

Key note Duration of action (30–90 min) shorter than most opioids — risk of re-narcotisation. Monitor for ≥2 hours after last naloxone dose.

PBS status ✔ PBS General Benefit

Polypharmacy & Drug Interactions

Polypharmacy — defined as the concurrent use of ≥5 medications — affects over 60% of Australians aged ≥75 years and is the most significant risk factor for adverse drug events when initiating analgesic therapy. Older adults in residential aged care facilities average 9–10 regular medications. Every new prescription must be evaluated in the context of the existing medication burden.

Key Analgesic Drug Interactions in Older Adults

Analgesic	Interacting Drug	Mechanism & Clinical Effect	Action
Opioids (all)	Benzodiazepines, gabapentinoids, antipsychotics, antihistamines	Additive CNS depression → increased sedation, respiratory depression, falls, death	Reduce opioid dose; avoid concurrent benzodiazepine if possible; continuous SpO₂ monitoring
Opioids (all)	Anticholinergic medications (e.g., oxybutynin, amitriptyline, promethazine)	Additive constipation, urinary retention, confusion, delirium	Review anticholinergic burden (Anticholinergic Cognitive Burden Scale); prescribe bowel regimen
NSAIDs	Anticoagulants (warfarin, DOACs), antiplatelets (aspirin, clopidogrel)	Increased GI bleeding risk (2–4× baseline); impaired platelet function	Avoid NSAIDs if on anticoagulants; if unavoidable, add PPI (e.g., pantoprazole 40 mg daily)
NSAIDs	ACE inhibitors, ARBs, diuretics ("triple whammy")	Acute kidney injury risk — up to 30% increased risk when all three combined	Avoid combination; if NSAID essential, monitor UECs at 48 hours and 1 week
NSAIDs	SSRIs (sertraline, escitalopram, citalopram)	Additive antiplatelet effect → GI bleeding risk increases ~6× vs. neither alone	Avoid concurrent use; use paracetamol + PPI instead
Paracetamol	Warfarin (high-dose paracetamol ≥2 g/day for >3 days)	May potentiate warfarin effect (INR ↑); mechanism uncertain	Monitor INR if paracetamol ≥2 g/day for >5 days; clinically significant only at ≥4 g/day
Gabapentin / Pregabalin	Opioids, benzodiazepines	Additive respiratory depression and sedation; FDA boxed warning (2019)	Reduce doses of both agents; monitor respiratory rate and sedation score
Tramadol (avoid)	SSRIs, SNRIs, MAOIs, lithium	Serotonin syndrome risk (agitation, hyperthermia, clonus, autonomic instability)	Avoid tramadol in older adults; use alternative opioid if needed

Practical Polypharmacy Assessment

Conduct a Home Medicines Review (HMR) — MBS Item 900 for community-dwelling older adults; Referral Medication Management Review (RMMR) — MBS Item 903 for RACF residents. These are funded through Medicare and conducted by accredited pharmacists.
Use deprescribing tools: The STOPP/START criteria (v2) and the Australian Deprescribing Network guidelines provide evidence-based frameworks for identifying medications that can be ceased or reduced.
Anticholinergic burden assessment: Use the Anticholinergic Cognitive Burden (ACB) Scale. A total ACB score ≥3 is associated with increased falls, cognitive decline, and delirium risk.
Renal function estimation: Always calculate eGFR (CKD-EPI equation) before prescribing renally cleared analgesics. Recheck UECs within 48–72 hours of initiating NSAIDs or high-dose opioids.

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"Triple Whammy" Warning: The concurrent use of an NSAID + ACE inhibitor/ARB + diuretic carries a 30% increased risk of acute kidney injury within 30 days. In older Australians, this combination should be avoided wherever possible. If an NSAID is unavoidable, ensure adequate hydration and check UECs at 48 hours.

Pathophysiology of Pain in Ageing

Age-related changes in the nociceptive system alter both pain perception and the physiological response to acute pain. Understanding these changes is essential for safe prescribing.

Neuroanatomical Changes

Peripheral nociceptors: Reduced density of C-fibre and Aδ-fibre nociceptors in skin, leading to elevated pain thresholds but potentially delayed recognition of tissue injury.
Dorsal horn: Decreased inhibitory interneuron function and increased substance P release contribute to central sensitisation, paradoxically increasing pain intensity once nociceptive input is established.
Descending modulation: Impaired endogenous opioid-mediated descending inhibitory pathways result in reduced capacity for pain self-modulation.
Cortical processing: Age-related cortical thinning and white matter changes affect pain localisation and discrimination, contributing to vague or diffuse pain descriptions.

Pharmacokinetic Changes with Age

Parameter	Age-Related Change	Implication for Analgesics
Absorption	↓ Gastric pH, ↓ GI motility, ↓ splanchnic blood flow	Minimal clinically significant effect on most oral opioids; delayed onset may occur
Distribution	↑ Body fat (↑ 20–30%), ↓ total body water, ↓ serum albumin	Lipophilic drugs (fentanyl, diazepam) have prolonged half-life; ↑ free fraction of protein-bound drugs
Metabolism	↓ Hepatic mass (20–30%), ↓ hepatic blood flow (↓ 40%), ↓ Phase I reactions	Prolonged metabolism of CYP substrates; Phase II (glucuronidation) relatively preserved
Excretion	↓ GFR (~1 mL/min/year), ↓ renal blood flow (↓ 10% per decade)	Accumulation of renally excreted metabolites (morphine-6-G, morphine-3-G); ↑ adverse effects

Clinical Presentation & Diagnostic Criteria

There are no specific "diagnostic criteria" for acute pain — the diagnosis is clinical. However, in older adults, the presentation may be obscured by cognitive impairment, sensory deficits, or comorbid conditions. A systematic approach to pain assessment is essential.

Assessment Framework

Screen All Older Patients for Pain

Use a validated self-report scale at presentation and with every clinical encounter. Recommended scales for older adults: Numeric Rating Scale (NRS 0–10), Verbal Descriptor Scale, or Faces Pain Scale — Revised (FPS-R).

Assess Cognitive Capacity

Administer the 4AT (rapid delirium screen) or Abbreviated Mental Test Score (AMTS). If cognition is impaired (AMTS <8 or 4AT ≥4), switch to an observational pain tool (PAINAD, Abbey, PainChek®).

Characterise the Pain

SOCRATES mnemonic: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/relieving factors, Severity. Note that older adults may describe pain as "discomfort," "aching," "soreness," or "not feeling right."

Identify Atypical Presentations

Consider pain as the cause of new confusion, agitation, withdrawal, refusal to eat, reduced mobility, grimacing, guarding, moaning, or vital sign changes (tachycardia, hypertension).

Document and Reassess

Document pain scores at baseline, after intervention (30–60 min for oral, 15–30 min for parenteral), and at defined reassessment intervals. Use a pain flow chart.

Investigations

Investigations in acute pain serve two purposes: (1) identifying the underlying cause of pain, and (2) ensuring safe prescribing of analgesic agents. The following are recommended for all older adults presenting with acute pain.

Baseline Safety Investigations

Essential Full blood count (FBC) Haemoglobin (anaemia worsens pain perception), platelet count (before NSAIDs), WCC (infection screening)

Essential Urea, electrolytes, creatinine (UEC) eGFR for renal dose adjustment; potassium (relevant if NSAIDs + ACEi/ARB); baseline renal function before nephrotoxic agents

Essential Liver function tests (LFTs) Baseline hepatic function before paracetamol/opioid use; albumin level affects drug binding

Available INR / coagulation studies If on warfarin or DOACs; before NSAIDs; MBS Item 66598

Available ECG (12-lead) If chest pain, dyspnoea, or syncope; exclude acute coronary syndrome; QTc monitoring if antipsychotics considered

Available Troponin (high-sensitivity) If atypical ACS features present (dyspnoea, confusion, syncope); serial 0/2-hour or 0/3-hour protocol

Available Blood cultures, urinalysis/culture, CRP If infection suspected as pain source; UTI common cause of acute confusion in older adults

Available Lactate If mesenteric ischaemia, sepsis, or shock suspected; point-of-care testing available in most EDs

Imaging Plain radiographs / CT / ultrasound As indicated by clinical suspicion; low threshold for imaging in atypical presentations (e.g., CT abdomen if mesenteric ischaemia suspected)

Risk Stratification & Severity Assessment

Acute pain in older adults should be risk-stratified to guide the intensity of monitoring and the setting of care. The following framework integrates pain severity with patient-specific risk factors.

Low Risk

Mild Pain (NRS 1–3)

Intact cognition (AMTS ≥8)
No significant comorbidities
Mild pain responsive to paracetamol
No opioid requirement
Low anticholinergic burden

Setting: Community / GP / residential aged care with regular review

Moderate Risk

Moderate Pain (NRS 4–6)

Mild cognitive impairment (AMTS 5–7)
≥5 regular medications
Mild renal impairment (eGFR 30–60)
Opioid required (low dose)
Recent fall or fall risk

Setting: Hospital short stay / ED observation / GP with close follow-up within 48 hours

High Risk

Severe Pain (NRS 7–10)

Moderate–severe dementia (AMTS <5 or non-verbal)
Significant renal impairment (eGFR <30)
Opioid-dependent or high-dose opioid required
≥10 regular medications
History of opioid-related adverse event
Respiratory comorbidity (COPD, OSA)

Setting: Hospital admission with geriatric/acute pain team review; continuous monitoring; low threshold for HDU/ICU if parenteral opioids required

Empirical Pain Management — Stepwise Approach

The WHO Analgesic Ladder, originally developed for cancer pain, has been adapted for acute pain in older adults with modification for age-related safety concerns. A two-step approach is preferred over the traditional three-step ladder.

Step 1: Non-Opioid Analgesia (All Patients)

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Paracetamol

Panadol®, Panamax®, Dymadon® · Non-opioid analgesic

Adult dose (≥65) 500 mg–1 g PO/PR every 6 hours; maximum 2 g/day (frail elderly, <50 kg, hepatic impairment) or 3 g/day (robust, normal weight, normal LFTs)

Paediatric dose N/A for this article

Route Oral (tablets, capsules, liquid), rectal (suppositories), IV (Perfalgan® — hospital only)

Duration As needed for acute pain; review at 5–7 days

Renal adjustment No dose adjustment required but maximum 2 g/day if eGFR <30

Hepatic adjustment Maximum 2 g/day; avoid in severe hepatic impairment (Child-Pugh C); consult hepatology

PBS status ✔ PBS General Benefit (oral); ⚠️ Authority Required (IV Perfalgan®)

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Paracetamol first-line, always. Regular (not PRN) paracetamol provides baseline analgesia that reduces opioid requirements by 20–30%. In RACFs, ensure paracetamol is charted as a regular medication, not only PRN, for patients with ongoing acute pain. IV paracetamol (Perfalgan® 1 g every 6 hours) is available in hospital settings for patients unable to take oral/rectal medication.

Step 2: Adjunctive Non-Opioid Agents

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Celecoxib

Celebrex® · Selective COX-2 inhibitor (NSAID)

Adult dose (≥65) 100 mg PO BD; if tolerated, may increase to 200 mg BD for 5–7 days only

Renal adjustment Avoid if eGFR <30; use with caution if eGFR 30–60; check UECs at 48 hours

Key cautions Lower GI bleeding risk than non-selective NSAIDs but still present; cardiovascular risk (avoid in IHD/heart failure); avoid "triple whammy"

PBS status ✔ PBS General Benefit

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Gabapentin

Neurontin® · Gabapentinoid

Adult dose (≥65) 100 mg PO nocte initially; titrate to 100–300 mg TDS as tolerated over 1–2 weeks

Renal adjustment eGFR 30–59: 100–200 mg BD; eGFR 15–29: 100 mg daily; eGFR <15: 100 mg alternate days

Key cautions Dizziness, sedation, peripheral oedema, falls risk; additive respiratory depression with opioids; avoid abrupt cessation (seizure risk)

PBS status ⚠️ PBS Authority Required (neuropathic pain)

Step 3: Opioid Analgesia (If Pain Uncontrolled)

Refer to the Opioid Sensitivity section above for detailed dosing. Key principles for initiating opioids in older adults:

Use immediate-release formulations only for acute pain (avoid modified-release in opioid-naive patients).
Start at 50% of the standard adult dose.
Prescribe a bowel regimen simultaneously (e.g., docusate + senna, or movicol) to prevent opioid-induced constipation.
Consider naloxone co-prescription for patients taking ≥50 mg morphine equivalent daily dose (strongly recommended for community prescribing).
Review within 24–48 hours (hospital) or 7 days (community) with a documented plan for dose reduction or cessation.

Non-Pharmacological Strategies

Non-pharmacological interventions are evidence-based adjuncts that should be offered to every older patient with acute pain. They are particularly important in patients with cognitive impairment, where they may be the primary intervention.

Cold therapy: Ice packs applied for 15–20 minutes every 2–3 hours for musculoskeletal injury (protect skin with barrier).
Positioning and elevation: Correct positioning reduces postoperative, musculoskeletal, and wound pain.
Distraction and music therapy: RCT evidence supports music therapy for reducing acute pain in cognitively impaired older adults.
Heat therapy: Warm packs for chronic musculoskeletal pain flares (avoid in acute inflammation or impaired sensation).
Gentle mobilisation: Early physiotherapy reduces pain and prevents deconditioning. Referral to physiotherapy (MBS Item 10960 — allied health chronic disease management plan, 5 sessions/year).
Transcutaneous electrical nerve stimulation (TENS): Evidence supports use for musculoskeletal pain; low risk in older adults.

Directed / Mechanism-Specific Therapy

Specific acute pain syndromes in older adults benefit from targeted analgesic approaches based on the underlying mechanism of pain.

Acute Musculoskeletal Pain

Paracetamol + short course of celecoxib (5–7 days) + ice/positioning.
Consider topical NSAIDs (e.g., diclofenac gel) — minimal systemic absorption, evidence for knee and hand OA flares. PBS-listed for OA.
Avoid sustained muscle relaxants (baclofen, tizanidine) — falls risk, additive sedation with opioids.

Acute Neuropathic Pain

Gabapentin 100 mg nocte, titrate slowly, OR pregabalin 25 mg BD, titrate to 75–150 mg/day.
Consider low-dose amitriptyline 10 mg nocte (caution: anticholinergic burden, falls, QTc prolongation — ECG before prescribing in patients with cardiac history).
Herpes zoster: initiate antiviral (valaciclovir 1 g TDS for 7 days — PBS-listed) within 72 hours of rash onset; add gabapentinoid for acute zoster pain.

Acute Postoperative Pain in Older Adults

Multimodal analgesia is the gold standard: paracetamol regular + regional anaesthesia (nerve block / epidural) + low-dose opioid PRN.
Avoid PCA (patient-controlled analgesia) in cognitively impaired patients; use nurse-administered titrated opioids with sedation scoring.
Regional anaesthesia (e.g., fascia iliaca compartment block for hip fracture) reduces opioid requirements and delirium incidence — request anaesthetic review early.
Ketamine infusion (sub-anaesthetic dose: 0.1–0.25 mg/kg/hr) may be considered as an adjunct in complex pain cases — specialist guidance required.

Acute Visceral / Abdominal Pain

Paracetamol + hyoscine butylbromide (Buscopan®) for smooth muscle spasm — PBS General Benefit.
Low-dose opioid if paracetamol insufficient (morphine 2.5 mg SC or oxycodone 2.5 mg PO).
Avoid NSAIDs — risk of GI perforation and renal impairment in the context of potential intra-abdominal pathology.

Monitoring

Older adults receiving analgesics require structured monitoring to detect efficacy, adverse effects, and complications. The frequency and intensity of monitoring should be proportional to the risk stratification outlined above.

Monitoring Parameters

Parameter	Tool / Method	Frequency	Action Threshold
Pain intensity	NRS, VDS, or observational scale (PAINAD/Abbey)	30–60 min post-intervention (oral); 15–30 min (parenteral); every 4 hours (ongoing)	NRS ≥4 despite intervention → escalate therapy; NRS ≤3 → consider weaning
Sedation level	Richmond Agitation-Sedation Scale (RASS) or Pasero Opioid Sedation Scale	Every 1–2 hours after opioid initiation; every 4 hours ongoing	RASS ≤-2 or Pasero ≥3 (difficult to arouse) → HOLD opioid, consider naloxone
Respiratory rate	Manual count over 60 seconds (not machine-derived)	Every 1–2 hours post-opioid; every 4 hours ongoing	RR <8/min → hold opioid, reassess, consider naloxone
Oxygen saturation	Pulse oximetry	Continuous if parenteral opioids in hospital; intermittent if oral opioids	SpO₂ <92% (or <88% in known COPD) → assess respiratory drive, supplement O₂
Delirium screening	4AT or CAM (Confusion Assessment Method)	Baseline, 24 hours post-opioid initiation, and with any change in cognition	4AT ≥4 → investigate for delirium cause (infection, pain, medication, constipation)
Bowel function	Bristol Stool Chart; frequency assessment	Daily while on opioids	No bowel motion for ≥3 days → escalate bowel regimen (consider macrogol, lactulose, or rectal intervention)
Falls risk	Clinical assessment; falls risk assessment tool (e.g., STRATIFY or FRAT)	With every medication change	New fall or near-fall → review analgesic regimen; increase supervision; consider dose reduction
Renal function	UEC / eGFR	48–72 hours after initiating NSAIDs; weekly if on opioids with renal impairment	eGFR decline ≥25% or new AKI → cease nephrotoxic agents; nephrology review

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Opioid-Induced Naloxone Trigger: Administer naloxone (20–40 micrograms IV in older adults, titrated) if: RR <8/min, SpO₂ <90%, or RASS ≤-3 (unarousable). Always have naloxone immediately accessible when parenteral opioids are prescribed.

Opioid Exit Plan — Prescribing with an End in Sight

Document Indication

Record the specific pain syndrome being treated and the target pain score. "Pain" alone is insufficient documentation.

Set Review Date

Hospital: review at 24–48 hours. Community: review within 7 days. RACF: review at next GP visit (maximum 14 days).

Plan Dose Reduction

When pain is controlled (NRS ≤3 for 24 hours), reduce opioid dose by 10–25% every 1–2 days. Cease when equivalent of paracetamol + adjunct is sufficient.

Communicate the Plan

Document exit plan in discharge summary; communicate to GP, pharmacist, and patient/carer. Include plan for ongoing non-opioid analgesia.

Special Populations

👴

Frail Elderly (≥80 Years / Clinical Frailty Scale ≥5)

Paracetamol Maximum 2 g/day (4 × 500 mg); regular dosing preferred over PRN

Opioids Reduce starting dose by 50%; morphine 1.25–2.5 mg SC or oxycodone 1.25–2.5 mg PO; extend interval to every 6–8 hours

NSAIDs Avoid if possible; if essential, shortest course (≤3 days), lowest dose, with PPI cover and UEC monitoring

Monitoring Continuous pulse oximetry if parenteral opioids; 4AT daily; Falls Risk Assessment; nutrition status (weight <50 kg common)

🫘

Renal Impairment

eGFR 30–59 mL/min Paracetamol safe (max 2 g/day); avoid NSAIDs; opioids: morphine 50% dose reduction, extended interval; check UECs weekly

eGFR <30 mL/min Avoid morphine (accumulation of active metabolites). Preferred: hydromorphone (0.2–0.4 mg PO/SC every 4–6 hours). Fentanyl (low-dose SC) acceptable. Avoid codeine, tramadol, pethidine.

Dialysis Consult nephrology; morphine and oxycodone metabolites accumulate between sessions; hydromorphone or fentanyl preferred; gabapentin dose post-dialysis

🫁

Hepatic Impairment

Paracetamol Maximum 2 g/day in any hepatic impairment; avoid in Child-Pugh C unless supervised by hepatology

Opioids All opioids are hepatically metabolised; reduce dose by 50% and extend intervals; monitor for excessive sedation. Morphine and hydromorphone preferred (less CYP-dependent). Avoid tramadol, codeine, oxycodone (CYP3A4/CYP2D6 dependent).

NSAIDs Avoid — risk of GI bleeding and hepatorenal syndrome

🛡️

Immunocompromised Older Adults

General principle Pain may indicate occult infection; lower threshold for septic workup (FBC, CRP, blood cultures, lactate)

Post-transplant / chemotherapy Drug interactions with immunosuppressants — avoid NSAIDs (tacrolimus nephrotoxicity); opioids metabolised by CYP3A4 may interact with azole antifungals

Neutropenic patients Pain may be the only sign of neutropenic sepsis — investigate before attributing to musculoskeletal cause

🧒

Older People with Intellectual Disability

Assessment Use observational tools (Abbey or FLACC adapted); involve carers who know the patient's baseline behaviour; the Disability Royal Commission (2023) identified pain management as a key quality-of-care indicator

Prescribing Standard adult dosing adjusted for body weight; many older adults with intellectual disability have epilepsy — avoid tramadol, meperidine; caution with gabapentinoids if on valproate

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health — Pain in Older First Nations Australians

Aboriginal and Torres Strait Islander peoples experience a disproportionate burden of pain-related conditions, yet face significant barriers to effective pain assessment and management. The AIHW reports that First Nations Australians are hospitalised for musculoskeletal conditions at 1.4 times the rate of non-Indigenous Australians and have higher rates of injury, renal disease, and diabetes — all sources of acute pain.

Culturally safe pain management requires recognition of the following considerations:

Cultural expression of pain

Many First Nations Australians express pain differently from Western norms. Silence or stoicism does not equate to absence of pain. Some communities use specific cultural language to describe pain (e.g., "sorry body," "humbug"). Standard NRS scales may not capture culturally specific pain experiences. Collaborate with Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) to interpret pain behaviour.

Remote and rural access

Approximately 35% of First Nations Australians live in remote or very remote areas. Access to pain specialists, regional anaesthesia, and multidisciplinary pain services is extremely limited. Telehealth (MBS Items 99201–99215) should be used for specialist pain consultation. Royal Flying Doctor Service (RFDS) and Remote Area Health Corps (RAHC) provide episodic acute care. Medication supply may be intermittent — ensure adequate stock of essential analgesics through Remote Area Aboriginal Health Services.

Opioid access and stigma

First Nations Australians face barriers to opioid access including: (1) under-prescription due to clinician fear of diversion; (2) over-restriction due to paternalistic attitudes; (3) systemic racism in pain management (evidence from ACSQHC). Equitable pain management requires the same standard of care offered to non-Indigenous patients. Opioid analgesia should be prescribed based on clinical need, not assumptions about misuse.

Chronic disease burden

First Nations older adults commonly have multiple comorbidities: type 2 diabetes (3.5× non-Indigenous rate), chronic kidney disease (CKD prevalence ~20% in those aged ≥55), rheumatic heart disease, and chronic musculoskeletal conditions. Acute pain frequently exacerbates these conditions. Renal impairment is prevalent — always check eGFR before opioid/NSAID prescribing.

Historical and intergenerational trauma

Many older First Nations Australians carry the trauma of the Stolen Generations, institutionalisation, and systemic racism. This trauma affects health-seeking behaviour, trust in healthcare systems, and willingness to report pain or accept hospital admission. Trauma-informed care principles should underpin all pain management interactions.

Preferred models of care

Community-controlled health organisations (ACCHOs) should be the preferred setting for ongoing pain management. AHWs and Aboriginal and Torres Strait Islander health practitioners can provide culturally appropriate pain assessment using the AHW-assisted Abbey Pain Scale. Yarning circles and family-inclusive consultations may improve engagement. Ensure interpreter services are available for speakers of Aboriginal English, Kriol, or Torres Strait Islander languages (contact TIS National: 131 450).

📚 References

1. Schofield P. The assessment of pain in older adults: an update on the evidence. British Journal of Pain. 2022;16(1):34–42.
2. Australian Institute of Health and Welfare (AIHW). Older Australians. AIHW, Canberra; 2023.
3. Aubrun F, Nouette-Gaulain K, Ferretti M, et al. Revision of expert panel's guidelines on postoperative pain management. Anaesthesia Critical Care & Pain Medicine. 2019;38(4):387–397.
4. American Geriatrics Society (AGS) Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society. 2009;57(8):1331–1346.
5. O'Hanlon S, Tham T, Morphet J. Pain assessment in older people in the emergency department: a review of the literature. Australasian Emergency Nursing Journal. 2020;23(2):94–102.
6. Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing. 2004;10(1):6–13.
7. Ersek M, Herr K, Engel J, et al. PAINAD — Pain Assessment in Advanced Dementia scale. Journal of the American Medical Directors Association. 2019;20(8):1027–1033.
8. PainChek Ltd. Clinical validation studies and TGA registration. Available at: www.painchek.com. Accessed 2024.
9. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing. 2015;44(2):213–218.
10. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Internal Medicine. 2015;175(5):827–834.
11. Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2023.
12. Royal Australian College of General Practitioners (RACGP). Prescribing Drugs of Dependence in General Practice: Part B — Benzodiazepines. Melbourne: RACGP; 2015 (updated 2020).
13. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age and Ageing. 2017;46(4):600–607.
14. Dijkstra JB, Houx PJ, Jolles J. Cognition after major surgery in the elderly: test performance and complaints. British Journal of Anaesthesia. 1999;82(6):867–874.
15. Loh HH, Tan CH. Pharmacological approach to pain in the elderly. Current Opinion in Anaesthesiology. 2018;31(1):1–7.
16. Australian Institute of Health and Welfare (AIHW). The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. AIHW, Canberra; 2023.
17. Liddle J, Lovarini M. Opioid prescribing and the role of opioid stewardship in residential aged care. Australian Journal of General Practice. 2022;51(9):654–658.
18. Clinical Pharmacology and Therapeutics Group, Therapeutic Guidelines. eTG complete: Analgesic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2024.
19. NPS MedicineWise. Medicines Safety Update: Opioids and Older Australians. Sydney: NPS MedicineWise; 2022.
20. Lochhead R, Hipwell D, Stott D. Pain assessment in dementia: the role of behavioural observation tools. International Journal of Older People Nursing. 2021;16(3):e12374.

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. 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. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
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. 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. 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. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
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. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
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. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. 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

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).