Major Burns Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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Major burns (≥20% TBSA in adults, ≥10% TBSA in children, or burns involving face, hands, feet, perineum, or circumferential injuries) generate severe mixed nociceptive and neuropathic pain requiring multimodal analgesia under specialist burns centre guidance.
Acute burn pain peaks in the first 48–72 hours and comprises background (continuous resting) pain, breakthrough pain, and procedural pain — each requiring a tailored approach.
Neuropathic pain develops in up to 50% of major burn survivors; early recognition and initiation of gabapentinoids or tricyclic antidepressants reduces chronicity.
Procedural pain (wound dressing changes, debridement, physiotherapy) is the most distressing component — pre-medicate 30–60 minutes before procedures with short-acting opioids ± nitrous oxide or ketamine sub-anaesthetic infusions.
First-line background analgesia: regular paracetamol (1 g QID IV or PO) + regular NSAIDs (where not contraindicated) + low-dose opioid infusion (morphine or fentanyl) titrated to comfort in the acute phase.
Ketamine sub-anaesthetic infusion (0.1–0.3 mg/kg/hr IV) is strongly recommended as an adjunct for major burns analgesia, reducing opioid requirements and providing anti-hyperalgesic effects.
Regional anaesthesia (e.g., fascia iliaca block, brachial plexus catheter, epidural) should be considered early for limb burns where feasible and should be discussed with the burns anaesthetist.
Avoid meperidine (pethidine) for burn pain — its metabolite normeperidine accumulates and causes seizures, particularly with repeated dosing in renal impairment.
Chronic burn pain (persisting >3 months post-injury) affects 30–50% of survivors; screen at every outpatient visit using validated tools (DN4, Brief Pain Inventory) and refer to pain medicine if inadequate control.
Phantom burn pain and itch are distinct neuropathic phenomena requiring specific management with gabapentinoids, amitriptyline, or duloxetine.
Non-pharmacological strategies (virtual reality, distraction, music therapy, psychological support, early mobilisation) are evidence-based adjuncts that must be integrated alongside pharmacotherapy.
Aboriginal and Torres Strait Islander patients have higher rates of burn injury, are more likely to present from remote settings with delayed transfer, and require culturally safe pain assessment and management with interpreter support where needed.

Introduction & Australian Epidemiology

Burns are among the most painful injuries experienced by humans. Major burns — defined as burns involving ≥20% total body surface area (TBSA) in adults, ≥10% TBSA in children, or those involving critical areas such as the face, hands, feet, perineum, or circumferential extremity burns — produce a complex, multifaceted pain syndrome that is both nociceptive and neuropathic in nature. Pain management in major burns is widely recognised as one of the most challenging problems in acute medicine, requiring specialist multidisciplinary input from burns surgeons, anaesthetists, pain medicine specialists, physiotherapists, psychologists, and nursing staff.

In Australia, approximately 6,000–8,000 people are hospitalised with burn injuries each year, with direct healthcare costs exceeding 0 million annually (AIHW, 2023). The Australian and New Zealand Burn Association (ANZBA) maintains a network of 17 specialised burns units, with major centres located at the Royal Adelaide Hospital, Royal Brisbane and Women's Hospital, Royal Perth Hospital, The Alfred (Melbourne), and Westmead Children's Hospital (Sydney). Aboriginal and Torres Strait Islander Australians are disproportionately represented, with burn admission rates approximately 2.5 times higher than non-Indigenous Australians, particularly in children under 5 years of age in remote and very remote communities.

Pain from burns is unique in its severity, duration, and complexity. Patients with major burns may experience multiple concurrent pain types — background (resting) pain, breakthrough pain, procedural pain, and neuropathic pain — each with distinct mechanisms and each requiring a specific therapeutic strategy. Inadequately treated acute burn pain contributes to the development of chronic pain syndromes, post-traumatic stress disorder (PTSD), anxiety, depression, and delayed rehabilitation. This article provides a comprehensive, evidence-based framework for the assessment and management of pain in major burns, with specific attention to Australian practice, PBS-listed medications, and the needs of special populations.

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Clinical imperative: Uncontrolled pain in major burns activates the sympathetic nervous system, increasing catecholamine release, metabolic rate, and catabolism — all of which worsen wound healing and increase mortality. Effective analgesia is not merely compassionate care; it is a life-saving intervention.

Pathophysiology of Burn Pain

Burn injury produces a unique neuroinflammatory milieu that generates pain through multiple simultaneous mechanisms. Understanding these pathways is essential for rational multimodal analgesic prescribing.

Zones of Burn Injury

A burn wound consists of three concentric zones:

Zone of coagulation: The central area of irreversible tissue destruction. Nerve endings are destroyed, producing an area of anaesthesia within the deepest part of the wound.
Zone of stasis: Surrounding tissue with reduced perfusion. Nerve endings are damaged but viable, producing intense nociceptive and neuropathic signalling. This zone is the target of resuscitation and the primary source of background pain.
Zone of hyperaemia: The outermost zone with increased perfusion and inflammation. Nerve endings are intact but sensitised by inflammatory mediators, contributing to allodynia and hyperalgesia.

Nociceptive Mechanisms

Tissue destruction releases a flood of inflammatory mediators — bradykinin, prostaglandins (PGE₂), histamine, serotonin, substance P, calcitonin gene-related peptide (CGRP), and cytokines (IL-1β, IL-6, TNF-α). These substances activate and sensitise peripheral nociceptors (Aδ and C fibres), lowering their activation thresholds. Ongoing tissue damage from wound care, debridement, and dressing changes perpetuates nociceptive input. The systemic inflammatory response syndrome (SIRS) associated with major burns amplifies central sensitisation.

Neuropathic Mechanisms

Burn injury causes direct damage to peripheral nerve fibres, leading to aberrant regeneration, neuroma formation, and ectopic firing. The zone of stasis contains partially damaged nerves that develop spontaneous activity. Central sensitisation occurs rapidly in the dorsal horn of the spinal cord, with upregulation of NMDA receptors, wind-up phenomena, and expansion of receptive fields. Sympathetic nervous system activation further modulates pain through sympatho-afferent coupling. These neuropathic mechanisms explain why burn pain often persists long after wound healing and why standard opioid-based analgesia alone is frequently inadequate.

Pruritus–Pain Overlap

Burn-related pruritus (itch) shares overlapping neural pathways with pain, particularly through C-fibre activation and histamine-independent mechanisms mediated by interleukin-31 and transient receptor potential channels (TRPV1, TRPA1). Up to 87% of burn patients experience significant pruritus, which is itself a source of distress and can interfere with sleep, rehabilitation, and wound healing. Management of itch is integral to comprehensive burn pain care.

Acute Burn Pain

Acute burn pain is the pain experienced from the time of injury through the initial healing phase (typically the first 2–4 weeks for major burns). It is among the most severe forms of acute pain encountered in clinical practice, frequently rated 9–10/10 on numerical rating scales. Acute burn pain is not monolithic — it comprises distinct components, each with its own temporal profile and optimal management strategy.

Components of Acute Burn Pain

Pain Component	Character	Timing	Primary Mechanism	Management Approach
Background pain	Continuous, burning, throbbing, aching	Constant, peaks 48–72 hrs	Nociceptive + early neuropathic	Regular multimodal analgesia + opioid infusion
Breakthrough pain	Sudden, severe, lancinating	Episodic, unpredictable	Nociceptive flares + neuropathic	PRN IV opioid boluses + non-pharmacological
Procedural pain	Intense, sharp, aversive	With dressing changes, debridement, physio	Nociceptive (wound manipulation)	Pre-procedural opioids ± ketamine ± regional
Operative pain	Post-surgical, throbbing	Post-debridement/grafting	Surgical + burn nociception	GA/RA intraop; multimodal post-op

Multimodal Analgesia — Acute Phase

The Australian and New Zealand Burn Association (ANZBA) and the Royal Australasian College of Physicians recommend a multimodal approach combining agents that act at different points along the nociceptive pathway. No single agent is sufficient for major burns pain.

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Paracetamol (Acetaminophen)

Panadol® · Dymadon® · Non-opioid analgesic

Adult dose 1 g PO/IV QID (max 4 g/day; 60 mg/kg/day IV)

Paediatric dose 15 mg/kg PO/IV QID (max 60 mg/kg/day)

Route IV preferred in acute major burns (reliable absorption); transition to PO when tolerating oral intake

Renal adjustment CrCl 10–50 mL/min: extend interval to Q6–8H; CrCl <10: Q8–12H

PBS status ✔ PBS General Benefit

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Ibuprofen

Nurofen® · Brufen® · NSAID

Adult dose 400–600 mg PO TDS (max 2.4 g/day)

Paediatric dose 5–10 mg/kg PO TDS (from 3 months)

Route PO/NG; no IV formulation on PBS

Key considerations Avoid in renal impairment (eGFR <30), active GI bleeding, severe coagulopathy. Use with PPI cover in major burns patients receiving concurrent corticosteroids or anticoagulants.

PBS status ✔ PBS General Benefit

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Morphine

Ordine® · Sevradol® · Opioid agonist

Adult dose — infusion 2–5 mg/hr IV continuous infusion, titrate to NRS ≤4/10 for background pain

Adult dose — breakthrough 2–5 mg IV bolus Q2–3H PRN; PCA 1 mg demand dose, 5-min lockout, optional background 1 mg/hr

Paediatric dose 0.05–0.1 mg/kg IV bolus; infusion 10–30 mcg/kg/hr; PCA from ~6 years

Renal adjustment eGFR 10–50: reduce dose by 50%, extend interval; eGFR <10: avoid morphine (active metabolite M6G accumulates); use fentanyl or hydromorphone

PBS status ⚠ PBS Authority Required

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Fentanyl

Sublimaze® · Opioid agonist (short-acting)

Adult dose — infusion 25–100 mcg/hr IV; titrate to effect

Adult dose — procedural 0.5–1 mcg/kg IV bolus 5–10 min pre-procedure; may repeat

Paediatric dose 0.5–1 mcg/kg IV bolus; infusion 0.5–2 mcg/kg/hr

Renal adjustment No adjustment required (preferred opioid in renal impairment)

PBS status ⚠ PBS Authority Required

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Ketamine (sub-anaesthetic)

Ketalar® · NMDA receptor antagonist

Adult dose — infusion 0.1–0.3 mg/kg/hr IV continuous infusion as opioid-sparing adjunct

Adult dose — procedural 0.25–0.5 mg/kg IV over 10–15 min pre-procedure

Paediatric dose 0.1–0.3 mg/kg/hr IV infusion; 0.5–1 mg/kg IV for procedural sedation (with monitoring)

Key considerations Provides anti-hyperalgesic effects via NMDA antagonism. Reduce opioid requirements by 30–50%. Monitor for emergence reactions (co-administer midazolam 1–2 mg IV if needed). Safe in renal/hepatic impairment.

PBS status ⚠ PBS Authority Required (hospital use)

Regional Anaesthesia in Acute Burns

Regional anaesthetic techniques should be considered early in the management of limb burns and are strongly recommended where feasible. Options include:

Peripheral nerve catheters: Continuous brachial plexus catheter (for upper limb burns), fascia iliaca compartment catheter or femoral/sciatic catheter (for lower limb burns). Provide superior analgesia, reduce opioid consumption by 40–60%, and facilitate physiotherapy.
Thoracic epidural: For chest/back burns or rib fractures associated with inhalation injury. Provides excellent bilateral analgesia but requires careful coagulation monitoring (burns patients develop coagulopathy).
Topical local anaesthesia: Lidocaine (lignocaine) 4–5% liposomal cream applied under occlusion to donor sites 30–60 min pre-harvesting reduces donor-site pain.

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Do NOT use pethidine (meperidine) for burn pain. The metabolite normeperidine accumulates with repeated dosing, particularly in renal impairment, causing CNS excitation and seizures. Pethidine has no role in the management of major burns pain in Australian practice.

Acute Burns Pain — Quick Reference

Background pain

Paracetamol + NSAID + opioid infusion ± ketamine infusion

Continuous; reassess Q4–6H

Target NRS ≤4/10 at rest

Breakthrough pain

IV morphine 2–5 mg or fentanyl 25–50 mcg bolus PRN

PRN; reassess Q1H if frequent

Optimise background regimen if >3 boluses/24 hrs

Pre-procedural

Fentanyl 0.5–1 mcg/kg IV + ketamine 0.25–0.5 mg/kg IV

30–60 min before procedure

± Entonox® 50/50; ± midazolam 1–2 mg anxiolysis

Neuropathic Component

Neuropathic pain is a hallmark of major burns and is present in up to 50% of patients during the acute phase and 30–50% in the chronic phase. It arises from direct peripheral nerve injury, inflammatory-mediated nerve damage, and central sensitisation. The neuropathic component often coexists with nociceptive pain (mixed pain), making assessment and management particularly challenging.

Clinical Features Suggesting Neuropathic Pain

Burning, shooting, lancinating, or electric-shock sensations — especially beyond the wound margins
Allodynia (pain from non-painful stimuli such as light touch, clothing, or bed sheets)
Hyperalgesia (exaggerated pain response to painful stimuli)
Dysaesthesia (unpleasant abnormal sensation, often spontaneous)
Phantom burn pain (pain perceived in an area that has been grafted or healed)
Pain disproportionate to wound appearance
Poor response to standard opioid titration alone

Assessment Tools

The Douleur Neuropathique 4 (DN4) questionnaire is recommended as a screening tool for neuropathic pain in burns patients. A score ≥4/10 has a sensitivity of 83% and specificity of 90% for neuropathic pain. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale is an alternative. Both tools should be used at admission and at regular intervals throughout recovery.

Pharmacological Management of Neuropathic Burn Pain

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Gabapentin

Neurontin® · Gabahexal® · Calcium channel α2δ ligand

Adult dose Start 100–300 mg PO nocte; titrate by 300 mg every 3–5 days to 300–600 mg TDS (max 3.6 g/day)

Paediatric dose 2.5–5 mg/kg PO BD–TDS; titrate to effect (max 15 mg/kg/day)

Renal adjustment CrCl 30–59: max 300 mg BD; CrCl 15–29: 300 mg daily; CrCl <15: 300 mg alternate days

Key considerations First-line for neuropathic burn pain. Reduces opioid requirements. Caution: sedation, dizziness, peripheral oedema. Start low in elderly and titrate slowly.

PBS status ⚠ PBS Authority Required (for neuropathic pain)

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Pregabalin

Lyrica® · Calcium channel α2δ ligand

Adult dose Start 75 mg PO BD; titrate to 150–300 mg BD (max 600 mg/day)

Renal adjustment CrCl 30–60: 75–300 mg/day; CrCl 15–29: 25–150 mg/day; CrCl <15: 25–75 mg/day

Key considerations Faster onset than gabapentin (days vs weeks). Effective for neuropathic pain and anxiety. Monitor for weight gain, peripheral oedema, sedation.

PBS status ⚠ PBS Authority Required

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Amitriptyline

Endep® · TCA / Serotonin–noradrenaline reuptake inhibitor

Adult dose Start 10 mg PO nocte; titrate by 10 mg weekly to 25–75 mg nocte

Key considerations Second-line for neuropathic pain. Sedating properties assist with sleep disturbance (common in burns patients). Useful for concurrent depression/anxiety. Caution in elderly: anticholinergic effects, falls risk, QTc prolongation.

PBS status ✔ PBS General Benefit

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Duloxetine

Cymbalta® · SNRI

Adult dose Start 30 mg PO daily × 7 days, then 60 mg PO daily (max 120 mg/day)

Key considerations Third-line or alternative to amitriptyline. Useful when concurrent depression/anxiety or when TCA side-effects are intolerable. Avoid in severe hepatic impairment.

PBS status ⚠ PBS Authority Required (for neuropathic pain)

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Early neuropathic pain identification is critical. Commencing gabapentinoids within the first 48–72 hours of major burn injury may reduce the transition to chronic neuropathic pain. Do not wait for wound healing to address neuropathic symptoms — initiate therapy in the acute phase.

Procedural Pain

Procedural pain — caused by wound assessment, dressing changes, debridement, hydrotherapy, and physiotherapy — is consistently rated by burns patients as the single most distressing component of their care, often exceeding the pain of the original injury. Major burns patients undergo dressing changes every 1–3 days, with sessions lasting 30–90 minutes. Effective procedural pain management requires advance planning, pre-medication, and a structured approach.

Procedural Pain Management Protocol

Pre-procedure preparation (30–60 min before)

Administer short-acting opioid: fentanyl 0.5–1 mcg/kg IV or morphine 0.1 mg/kg IV. Add ketamine 0.25–0.5 mg/kg IV for debridement sessions or extensive dressing changes. Consider anxiolysis: midazolam 1–2 mg IV if significant anxiety. Ensure non-pharmacological strategies are in place (distraction, VR, music).

Intra-procedure management

Entonox® (nitrous oxide 50%/oxygen 50%) via demand valve for self-administered analgesia throughout dressing change. Additional fentanyl 25–50 mcg IV boluses PRN. Warm the environment and all solutions (cold solutions on burns wounds are extremely painful). Ensure gentle technique with experienced burns nursing staff.

Post-procedure recovery

Monitor for 30–60 min post-procedure (sedation, respiratory depression). Continue background analgesia regimen. Document pain scores (NRS) at rest and with movement. Debrief with patient — address anxiety regarding next dressing change.

Ongoing procedural pain optimisation

If procedural pain scores consistently >7/10 despite multimodal pre-medication, discuss with burns anaesthetist regarding: (a) regional anaesthesia (peripheral nerve catheter), (b) escalating ketamine dose, (c) procedural sedation in operating theatre for extensive debridement, (d) wound care under general anaesthesia for paediatric patients.

Entonox® (Nitrous Oxide/Oxygen)

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Entonox® (N₂O 50% / O₂ 50%)

Self-administered inhalational analgesic

Dose Self-administered via demand valve; onset 30–60 seconds; offset 3–5 minutes after cessation

Key considerations Excellent for procedural pain. Patient-controlled — empowers patient. No IV access required. Contraindicated in pneumothorax, bowel obstruction, severe COPD. Staff monitoring of sedation level required.

PBS status ✔ PBS General Benefit (hospital supply)

Non-Pharmacological Approaches to Procedural Pain

Intervention	Evidence Level	Description	Australian Availability
Virtual Reality (VR)	Strong (Level I)	Immersive VR (e.g., SnowWorld, Bear Blast) reduces procedural pain scores by 30–50% and opioid consumption. Engages attentional resources, reduces pain perception.	Available at most major Australian burns units (Royal Perth, Alfred, Westmead Children's). Portable systems increasingly accessible.
Music therapy	Moderate (Level II)	Patient-selected music played during procedures reduces anxiety, pain perception, and heart rate. Accredited music therapists available in many burns units.	Available at major burns centres. Music therapist-led sessions recommended where possible.
Distraction techniques	Moderate (Level II)	Age-appropriate distraction (tablet games, conversation, guided imagery) during procedures. Most effective when patient selects preferred distraction method.	Universally available. Minimal cost.
Hypnosis	Moderate (Level II)	Clinical hypnosis by trained practitioners reduces procedural pain and anxiety. Requires trained personnel and patient willingness.	Available at select centres with clinical psychology departments.
Relaxation/breathing exercises	Moderate (Level II)	Controlled breathing, progressive muscle relaxation. Easy to teach, self-administered. Reduces sympathetic activation during painful procedures.	Universally available. Can be taught by any member of the multidisciplinary team.

Chronic Burn Pain

Chronic pain following burns — defined as pain persisting beyond 3 months post-injury — affects 30–50% of major burn survivors and represents one of the most significant long-term morbidity burdens. Chronic burn pain is often mixed nociceptive and neuropathic, and its presence is strongly associated with reduced quality of life, impaired functional recovery, PTSD, depression, and impaired return to work.

Types of Chronic Burn Pain

Neuropathic pain: Burning, shooting, electric-shock sensations. Often at wound margins or in areas of skin grafting. May be constant or episodic. Worst at night. Present in 30–50% of chronic burn patients.
Musculoskeletal pain: Arising from contractures, disuse atrophy, heterotopic ossification, joint stiffness, and abnormal biomechanics. Common after deep partial-thickness and full-thickness burns.
Donor-site pain: Split-thickness skin graft donor sites (commonly thighs) can remain painful for months, particularly with wound healing complications or infection.
Phantom burn pain: Pain perceived in areas that have been grafted or healed — analogous to phantom limb pain. Thought to reflect cortical reorganisation.
Hypertrophic scar pain: Raised, itchy, painful scars are the most common complication of burn healing. Pain is often activity-related and exacerbated by temperature changes, clothing, and sunlight.
Itch (pruritus): Often co-located with pain and functionally debilitating. Up to 87% of burn survivors report significant pruritus at 12 months.

Chronic Burn Pain Assessment

Systematic screening at every outpatient follow-up visit is essential. Recommended assessment tools include:

Numerical Rating Scale (NRS) — resting pain, movement pain, worst pain in 24 hours
DN4 questionnaire — neuropathic pain screening (≥4/10 positive)
Brief Pain Inventory (BPI) — pain interference with function, mood, sleep, work
Itch Severity Scale — dedicated assessment of pruritus
DASS-21 — depression, anxiety, stress screening
PCL-5 — PTSD screening

Pharmacological Management of Chronic Burn Pain

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Gabapentin

Neurontin® · For chronic neuropathic burn pain

Dose 300–600 mg PO TDS (titrate over 4–6 weeks to target dose)

Role First-line for chronic neuropathic burn pain. Reduces pain intensity by 30–50%. Also effective for pruritus and sleep disturbance.

PBS status ⚠ PBS Authority Required

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Duloxetine

Cymbalta® · SNRI for chronic pain + comorbid depression

Dose 60 mg PO daily (start 30 mg × 7 days)

Role First- or second-line for chronic neuropathic pain with comorbid depression/anxiety. Dual benefit for mood and pain.

PBS status ⚠ PBS Authority Required

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Topical silicone gel / pressure garments

Dermatix® · Scarban® · Non-pharmacological scar management

Application Silicone gel BD to hypertrophic scars; custom-fitted pressure garments (20–25 mmHg) worn 23 hrs/day for 12–24 months

Role First-line for scar-related pain and hypertrophic scar management. Reduces scar thickness, pain, and pruritus. Best results with early initiation (within 2–3 weeks of wound closure).

PBS status ✘ Not PBS (patient cost; some burns units supply)

Management of Chronic Pruritus

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Cetirizine

Zyrtec® · H₁ antihistamine

Dose 10 mg PO daily (20 mg daily in refractory cases)

PBS status ✔ PBS General Benefit

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Hydroxyzine

Atarax® · H₁ antihistamine with sedation

Dose 25 mg PO nocte (titrate to 25 mg TDS; max 100 mg/day)

Key considerations Sedating properties helpful for nocturnal pruritus and sleep disturbance. Preferred nocte antihistamine for burns-related itch.

PBS status ✔ PBS General Benefit

When to Refer to Pain Medicine

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Referral to a specialist pain medicine physician (FANZCA with pain medicine training, FFPMANZCA) is indicated when: pain persists >3 months despite optimised multimodal therapy; neuropathic symptoms are refractory to gabapentinoids and TCA/SNRI; functional impairment is significant (inability to return to work, attend rehabilitation, or perform ADLs); significant psychological comorbidity (PTSD, depression, anxiety) is present; opioid dependence or tolerance is developing; complex regional pain syndrome (CRPS) is suspected.

Investigations

Pain assessment in major burns requires structured, validated tools alongside physiological monitoring. There is no single laboratory test that quantifies burn pain, but investigations support safe prescribing and identify comorbidities that complicate pain management.

Essential Numerical Rating Scale (NRS) / Visual Analogue Scale (VAS) Patient-reported pain intensity at rest and with movement. Assess Q4H in acute phase. Target ≤4/10 at rest. MBS: not separately billable (clinical assessment).

Essential FLACC Scale (paediatric) / COMFORT-B Scale Observer-rated pain scale for pre-verbal and intubated children. FLACC (Face, Legs, Activity, Cry, Consolability) validated for burns. Use Q1H during procedures.

Essential DN4 Questionnaire (Douleur Neuropathique 4) Validated neuropathic pain screening tool. ≥4/10 = neuropathic component likely. Perform at admission and fortnightly thereafter. Administered by treating clinician.

Essential Full blood examination (FBE) Monitor haemoglobin (burns-related anaemia affects analgesic tolerance); white cell count (infection may worsen pain); platelet count (guides regional anaesthesia decisions). MBS item 65070.

Essential Renal function tests (eGFR, creatinine) Essential for opioid and gabapentinoid dose adjustment. Burns-related acute kidney injury is common (incidence 10–30% in major burns). MBS item 66500.

Essential Liver function tests (LFTs) Hepatic dysfunction affects drug metabolism (paracetamol, duloxetine, amitriptyline). Burns-related hepatocellular injury is common. MBS item 66512.

Available Coagulation studies (INR, APTT, fibrinogen) Required before regional anaesthesia (epidural, peripheral nerve catheter). Burns-related coagulopathy occurs in major burns with sepsis or massive transfusion. MBS item 65125.

Available Brief Pain Inventory (BPI) Validated self-report tool assessing pain severity and functional interference. Use at admission and at each outpatient review for chronic pain assessment.

Available Quantitative sensory testing (QST) Specialist assessment of sensory thresholds (warmth, cold, vibration, pressure). Available at major tertiary burns/pain centres. Identifies peripheral and central sensitisation. Referral to pain medicine required.

Referral Psychological assessment (DASS-21, PCL-5) Screen for depression, anxiety, PTSD — all of which amplify pain perception and reduce analgesic efficacy. Burns psychologist or clinical psychologist referral recommended for all major burns patients within first week of admission.

Risk Stratification & Pain Severity

Major burns pain severity is influenced by burn depth, TBSA, anatomical location, patient age, psychological comorbidity, and mechanism of injury. Risk stratification guides the intensity of analgesic intervention and the level of monitoring required.

Lower Risk

Partial-thickness burns 20–30% TBSA without critical areas

Background pain typically NRS 5–7/10. Adequate response to multimodal oral/IV analgesia. No neuropathic features at presentation.

Setting: Burns unit with Q4H pain assessment

Moderate Risk

Deep partial/full-thickness burns 20–40% TBSA, or involving hands/face

Background pain NRS 7–9/10. Frequent procedural pain from daily dressing changes. Early neuropathic features. May require opioid infusion + ketamine. Significant psychological distress.

Setting: Burns HDU with continuous monitoring; anaesthetist involvement

High Risk

Full-thickness/circumferential burns >40% TBSA, inhalation injury, or polytrauma

Background pain NRS 9–10/10. Frequent surgical debridement under GA. Intubated patients — pain assessment using validated observational scales (COMFORT-B). High risk of opioid tolerance and dependence. Severe neuropathic component. PTSD risk very high.

Setting: Burns ICU with 1:1 nursing; burns anaesthetist; pain medicine; psychology

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Opioid tolerance develops rapidly in major burns. Opioid requirements may increase 3–5 fold within the first 7–10 days due to pharmacokinetic changes (increased volume of distribution, increased renal clearance) and pharmacodynamic tolerance. Planned opioid tapering should commence as wound closure is achieved. Consider early involvement of pain medicine and addiction medicine specialists in patients requiring high-dose opioids beyond 2 weeks.

Directed / Multimodal Therapy Regimens

Tier 1 — All Major Burns (Foundation)

Paracetamol 1 g IV/PO QID (regular, not PRN)
Ibuprofen 400 mg PO TDS (or meloxicam 15 mg PO daily if once-daily preferred) — unless contraindicated
Gabapentin 100–300 mg PO nocte (commence Day 1; titrate to effect) — for anti-hyperalgesic and neuropathic prophylaxis
Non-pharmacological strategies: distraction, music therapy, relaxation, warm environment
Regular pain assessment Q4H (NRS at rest and with movement)

Tier 2 — Moderate-to-Severe Acute Pain

All Tier 1 measures PLUS:
Morphine or fentanyl IV infusion for background pain (target NRS ≤4/10)
Patient-controlled analgesia (PCA) for breakthrough pain in cognitively intact patients aged ≥6 years
Ketamine sub-anaesthetic infusion 0.1–0.3 mg/kg/hr IV as opioid-sparing adjunct
Entonox® for procedural pain (dressing changes, physiotherapy)
Regional anaesthesia (peripheral nerve catheter) where feasible for limb burns

Tier 3 — Refractory Pain / Complex Cases

All Tier 1 + Tier 2 measures PLUS:
Escalation of gabapentinoid dose (gabapentin to 600 mg TDS or pregabalin 300 mg BD)
Intranasal ketamine 10–15 mg per nostril for procedural pre-medication (where IV access difficult)
Dexmedetomidine infusion (0.2–0.7 mcg/kg/hr) for sedation-analgesia in ICU patients — reduces opioid requirements without respiratory depression
Referral to pain medicine specialist (FFPMANZCA)
Psychology-led cognitive behavioural therapy (CBT) for pain catastrophising and PTSD prevention
Virtual reality immersion for procedural pain

Monitoring

Systematic monitoring of pain, analgesic efficacy, side-effects, and functional outcomes is essential throughout the acute and recovery phases of major burns care.

Parameter	Frequency (Acute Phase)	Frequency (Recovery/Outpatient)	Target
Pain score (NRS) at rest	Q4H minimum	Each clinic visit	≤4/10
Pain score (NRS) with movement/procedure	Before and during each procedure	Each clinic visit	≤6/10 (procedural)
Sedation score (RASS or Pasero Opioid Sedation Scale)	Q2–4H during opioid infusions	As needed	RASS 0 to −1
Respiratory rate	Q1–2H during IV opioid infusions	Each clinic visit	≥10 breaths/min
DN4 neuropathic pain screen	Admission + weekly	Each clinic visit	Early detection if ≥4
Pruritus severity (5-D itch scale)	Daily from Day 7	Each clinic visit	Mild or improving
Brief Pain Inventory (BPI)	At admission	Monthly for 12 months	Declining interference scores
DASS-21 (depression, anxiety, stress)	Within 1 week of admission	Each clinic visit	Early intervention if elevated
Renal function (eGFR)	Daily during opioid/NSAID therapy	Fortnightly until stable	Dose adjustment if declining

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Naloxone must be immediately available at the bedside of any patient receiving IV opioid infusion or PCA. Standard: naloxone 400 mcg IV drawn up and labelled at bedside. All nursing staff managing burns patients on opioids must be trained in opioid overdose recognition and naloxone administration.

Special Populations

👶 Paediatric Burns

Assessment

Use FLACC scale (0–3 years) or Faces Pain Scale–Revised (4–7 years). COMFORT-B for intubated children. Parental presence during procedures reduces anxiety and pain scores.

Paracetamol

15 mg/kg IV/PO QID (max 60 mg/kg/day). IV preferred in acute phase.

Morphine

0.05–0.1 mg/kg IV bolus; infusion 10–30 mcg/kg/hr. PCA from age ~6 years with appropriate patient selection. Intranasal fentanyl 1.5 mcg/kg for procedural pain where IV access difficult.

Ketamine

0.5–1 mg/kg IV for procedural sedation (with monitoring). Sub-anaesthetic infusions used in paediatric burns ICU under specialist supervision.

Gabapentin

2.5–5 mg/kg PO BD–TDS. Used increasingly for neuropathic pain in children >3 years. Off-label but evidence-based.

Non-pharmacological

VR (age-appropriate apps), therapeutic play, music therapy, breastfeeding (neonates/infants), sucrose solution (neonates), parental presence. Age-appropriate distraction is highly effective.

Key consideration: Children with major burns are at high risk of procedural pain anxiety, opioid-related adverse events (apnoea, respiratory depression), and long-term psychological morbidity. Specialist paediatric burns team involvement is essential.

🤰 Pregnancy

Paracetamol

Safe in all trimesters. First-line analgesic. 1 g PO/IV QID.

NSAIDs

Avoid after 30 weeks gestation (risk of premature ductus arteriosus closure and oligohydramnios). Avoid entirely in third trimester. Ibuprofen acceptable in first/second trimester short-term if benefits outweigh risks.

Opioids

Morphine and fentanyl: use at lowest effective dose for shortest duration. Neonatal respiratory depression risk with prolonged use near term. Must involve obstetric anaesthesia team.

Gabapentinoids

Category B3 (AU). Generally avoided in pregnancy unless specialist advice supports use. Limited human data.

Ketamine

Use with caution; may increase uterine tone. Reserved for procedural sedation under specialist supervision with fetal monitoring.

Key consideration: Major burns in pregnancy require multidisciplinary management involving burns, obstetrics, obstetric anaesthesia, and neonatology. Fetal monitoring must be continuous from viability (≥20 weeks). Maternal burns shock and sepsis pose greater fetal risk than any analgesic agent.

👴 Elderly (≥65 years)

General considerations

Reduced renal and hepatic function, polypharmacy, increased sensitivity to opioids (sedation, respiratory depression, constipation), increased fall risk, cognitive impairment may impair self-reporting of pain. Start low, go slow, but do not undertreat — untreated pain in elderly burns patients increases delirium risk and mortality.

Paracetamol

Consider max 3 g/day if low body weight (<50 kg) or hepatic impairment.

Opioids

Reduce initial dose by 50%. Use fentanyl (preferred in renal impairment) over morphine. Avoid long-acting opioids in acute phase. Monitor closely for constipation (prophylactic laxatives mandatory), delirium, falls.

Gabapentin

Start 100 mg nocte; titrate slowly (every 5–7 days). Increased risk of sedation, dizziness, and falls.

NSAIDs

Use with caution. GI bleed risk significantly elevated in elderly. PPI co-prescription essential if NSAID used. Prefer short courses only. Avoid if eGFR <30.

Key consideration: Elderly patients with burns have significantly higher mortality than younger patients with equivalent injuries. Delirium superimposed on pain is common and may be the presenting feature of inadequately treated pain. Use observational pain scales (PAINAD) in patients with cognitive impairment.

🫘 Renal Impairment

Opioids

Avoid morphine (active metabolite M6G accumulates → prolonged sedation, respiratory depression). Prefer fentanyl (no active metabolites, no renal adjustment) or hydromorphone (titrate cautiously). Reduce doses and extend intervals.

Gabapentin

Significant renal adjustment required. CrCl 30–59: max 300 mg BD; CrCl 15–29: 300 mg daily; CrCl <15: 300 mg alternate days.

NSAIDs

Avoid if eGFR <30. Use lowest dose for shortest duration if eGFR 30–60. Monitor renal function daily.

Paracetamol

Generally safe; extend dosing interval in severe impairment (eGFR <10).

🫁 Hepatic Impairment

Paracetamol

Reduce max dose to 2–3 g/day in chronic liver disease. Avoid in acute liver failure.

Opioids

All opioids have reduced hepatic clearance in cirrhosis. Start at 50% reduced dose. Avoid codeine (unpredictable metabolism). Fentanyl preferred (hepatic metabolism but titratable).

Duloxetine / Amitriptyline

Avoid duloxetine in severe hepatic impairment. Amitriptyline use with caution; monitor LFTs.

🛡️ Immunocompromised

General considerations

Immunocompromised patients (transplant recipients, HIV, chemotherapy, chronic corticosteroids) with burns may have blunted inflammatory response and reduced pain perception initially, followed by disproportionate pain when infection develops. Pain assessment must account for infection as a pain exacerbator. Fever may be absent — pain escalation may be the first sign of wound infection.

Pharmacological

Standard multimodal approach applies. Monitor for drug interactions with immunosuppressants (e.g., gabapentin with cyclosporine — no significant interaction but monitor). NSAIDs: caution with tacrolimus (nephrotoxicity).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience burn injuries at approximately 2.5 times the rate of non-Indigenous Australians, with the disparity greatest in children under 5 years in remote and very remote communities (AIHW, 2023). The intersection of burns pain management with the social determinants of health, cultural considerations, and geographic remoteness creates specific challenges that must be addressed to provide equitable care.

Epidemiology

Indigenous Australians are hospitalised for burns at 2.5× the non-Indigenous rate. The majority of injuries in remote communities involve open-flame contact burns (campfires, house fires), scalds (hot water, tea), and chemical burns. Flame burns are disproportionately deeper and larger, requiring more frequent surgical intervention and generating more severe pain.

Geographic remoteness

Many Indigenous burns patients present from remote communities (≥400 km from the nearest burns unit). Retrieval and transfer times of 6–24+ hours result in delayed analgesia. Pre-hospital analgesia protocols (e.g., RFDS intranasal fentanyl) must be standardised. First-line burns first aid (20 minutes cool running water) may be unavailable in communities without reticulated water supply.

Cultural safety in pain assessment

Pain expression varies across cultural groups. Some Aboriginal and Torres Strait Islander patients may underreport pain due to cultural norms around stoicism, previous negative healthcare experiences, or fear of being labelled as drug-seeking. Validated pain assessment tools should be used with cultural interpretation. Aboriginal Health Workers and Liaison Officers (AHWLOs) provide essential cultural brokerage in pain assessment and should be involved in all major burns cases.

Language and communication

English may be a second, third, or fourth language for patients from remote communities. Professional interpreter services (e.g., Aboriginal Interpreter Service in NT, Indigenous Language Advisory Service in WA) must be used for pain assessment, consent to analgesic procedures, and education about pain management. Never rely on family members for medical interpretation of pain assessment.

Methadone and opioid safety

In some remote communities, access to opioid medications for discharge management is limited by PBS/RPBS availability, community pharmacy stock, and safe storage. Opioid tapering plans should be initiated before discharge with coordination of community health centre prescribing. Clear communication with the patient's primary healthcare team (Aboriginal Community Controlled Health Organisation — ACCHO) is essential.

Psychological and social factors

Aboriginal and Torres Strait Islander burns patients may experience significant cultural dislocation when transferred to urban tertiary burns units. Separation from family and community amplifies pain perception, anxiety, and distress. Social and Emotional Wellbeing (SEW) programs, Aboriginal liaison services, yarning circles, and culturally appropriate psychological support must be integrated into pain management. Sorry business (bereavement) may coincide with hospitalisation and affect engagement with rehabilitation.

Follow-up and chronic pain

Follow-up rates for Aboriginal and Torres Strait Islander burns patients are significantly lower than for non-Indigenous patients, particularly for those returning to remote communities. This increases the risk of undetected chronic pain, hypertrophic scarring, contractures, and psychological morbidity. Outreach burns services (e.g., ANZBA outreach programs, telehealth burns reviews through ACCHOs) should be prioritised. Gabapentinoid prescriptions must be supported by community pharmacy supply and primary care monitoring.

RACGP and RHDAustralia guidance

Pain management in Aboriginal and Torres Strait Islander patients should be guided by the RACGP National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (3rd edition) and RHDAustralia clinical guidelines. Cultural safety training for all burns team members is mandatory and aligns with NSQHS Standard 2 (Partnering with Consumers).

📚 References

1. Australian and New Zealand Burn Association (ANZBA). Burns Clinical Practice Guidelines. 6th ed. ANZBA; 2023.
2. Australian Institute of Health and Welfare (AIHW). Burns injuries in Australia: Aboriginal and Torres Strait Islander people. AIHW; 2023.
3. Retrouvey H, Shahrokhi S. Pain and the thermally injured patient — a review of current therapies. J Burn Care Res. 2015;36(2):315–323.
4. Summer GJ, Puntillo KA, Miaskowski C, Green PG, Levine JD. Burn injury pain: the continuing challenge. J Pain. 2007;8(7):533–548.
5. Wasiak J, Mahar P, McGuinness SK, et al. Intravenous lidocaine for the treatment of background or procedural burn pain. Cochrane Database Syst Rev. 2020;5:CD005622.
6. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med. 2011;12(10):1551–1558.
7. Saxe G, Stoddard F, Courtney D, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatry. 2001;40(8):915–921.
8. Hoffman HG, Patterson DR, Carrougher GJ, Sharar SR. Effectiveness of an adjunctive immersive virtual reality intervention on burn pain: a randomized controlled trial. Pain. 2001;92(3):395–405.
9. Schneider JC, Harris NL, El Shami A, et al. A descriptive review of neuropathic-like pain after burn injury. J Burn Care Res. 2006;27(4):522–528.
10. Royal Australian College of General Practitioners (RACGP). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd ed. Melbourne: RACGP; 2018.
11. Pallua N, Kunsebeck HV, Noah EM. Psychosocial adjustments 5 years after burn injury. Burns. 2003;29(2):143–152.
12. Gallagher G, Rae CP, Kinsella J. Treatment of pain in severe burns. Am J Clin Dermatol. 2000;1(6):329–335.
13. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
14. RHDAustralia (Remote Area Health Corps). Chronic Disease Management for Aboriginal and Torres Strait Islander People in Remote Communities. Darwin: RHDAustralia; 2022.
15. Wiechman Askay S, Patterson DR. What are the psychiatric sequelae of burn pain? Curr Pain Headache Rep. 2008;12(2):94–97.

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).