Neuropathic Pain Syndromes

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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Neuropathic pain arises from a lesion or disease of the somatosensory nervous system, affecting an estimated 5–8% of the Australian population and increasing with age.
Characterised by spontaneous burning, shooting, electric-shock sensations and evoked phenomena including allodynia (pain from a normally non-painful stimulus) and hyperalgesia (exaggerated pain response).
Screen with the DN4 questionnaire (score ≥ 4/10 suggestive) or painDETECT (≥ 19/38); clinical examination should include bedside sensory testing with brush, pin, cold, and vibration.
First-line pharmacological adjuvants are TCA (amitriptyline) or SNRI (duloxetine); gabapentinoids (pregabalin, gabapentin) are alternatives, particularly for peripheral neuropathic pain.
All first-line agents are PBS Authority Required for neuropathic pain — initiate at low dose and titrate slowly over weeks to balance efficacy and tolerability.
Opioids are NOT first-line and should only be considered short-term when adjuvants fail; long-term opioid therapy for neuropathic pain has limited evidence and significant harm.
Topical agents — capsaicin 8% patch (Qutenza®) and lidocaine 5% patch — are useful for localised peripheral neuropathic pain (e.g. post-herpetic neuralgia).
Combination therapy (e.g. TCA + gabapentinoid) may be needed when monotherapy is inadequate; trial each agent for at least 6–8 weeks at therapeutic dose before switching.
Non-pharmacological approaches — CBT-based pain management, graded motor imagery, exercise therapy, and TENS — are integral to multidisciplinary care.
Procedural options (nerve blocks, spinal cord stimulation, pulsed radiofrequency) are reserved for refractory cases and require specialist referral through a multidisciplinary pain service.
Trigeminal neuralgia is a unique entity — carbamazepine (or oxcarbazepine) is first-line; MRI brain with posterior fossa views is mandatory to exclude secondary causes.
Aboriginal and Torres Strait Islander Australians have higher prevalence of diabetic neuropathy and post-herpetic neuralgia; culturally safe screening and access to specialist pain services must be prioritised.

Introduction & Australian Epidemiology

Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as pain caused by a lesion or disease of the somatosensory nervous system. It is distinct from nociceptive pain and requires a fundamentally different approach to assessment and management. This article covers clinical features, validated screening tools, pharmacological adjuvants, and procedural interventions relevant to Australian primary care and specialist practice.

In Australia, population-based studies estimate that neuropathic pain affects approximately 5–8% of adults, with higher prevalence in those over 65 years and in people living with diabetes mellitus. The Australian Institute of Health and Welfare (AIHW) reports that chronic pain conditions, including neuropathic pain, account for a substantial burden of disease and are a leading cause of disability-adjusted life years (DALYs).

Common aetiologies encountered in Australian practice include:

Peripheral: Diabetic peripheral neuropathy (most common cause nationally), post-herpetic neuralgia (PHN), chemotherapy-induced peripheral neuropathy (CIPN), HIV-associated neuropathy, post-surgical neuropathy, radiculopathy, nerve entrapment.
Central: Post-stroke pain, spinal cord injury pain, multiple sclerosis-related pain.
Mixed: Complex regional pain syndrome (CRPS), trigeminal neuralgia.

The economic burden is significant: chronic neuropathic pain costs the Australian healthcare system an estimated billion annually when direct healthcare costs, lost productivity, and informal care are included (Painaustralia, 2019). Multidisciplinary management in line with the National Strategic Action Plan for Pain Management (2019) is the recommended approach.

Clinical Features

Neuropathic pain has characteristic clinical features that distinguish it from nociceptive pain. A thorough history and focused neurological examination are essential for diagnosis.

Spontaneous (Ongoing) Symptoms

Burning pain: Continuous or intermittent burning sensation, often described as "hot water" or "sunburn" — most common descriptor in diabetic neuropathy and PHN.
Shooting / lancinating pain: Brief, sharp, electric-shock-like pains; characteristic of trigeminal neuralgia and diabetic neuropathy.
Tingling and paraesthesiae: "Pins and needles," numbness, or a sensation of ants crawling (formication).
Dysaesthesiae: Unpleasant, abnormal sensations that may be continuous or provoked.

Evoked Phenomena

Phenomenon	Definition	Bedside Test	Significance
Allodynia	Pain from a stimulus that does not normally provoke pain	Light cotton-wool brush across affected area	Indicates central sensitisation; common in CRPS, PHN
Static mechanical hyperalgesia	Increased pain to a mild pressure stimulus	Finger pressure over affected dermatome	Peripheral sensitisation; seen in peripheral nerve injury
Pin-prick hyperalgesia	Exaggerated pain response to a pin-prick	Standard neurological pin or toothpick	Indicates central sensitisation spreading beyond lesion zone
Cold allodynia	Pain from a cool (non-noxious) stimulus	Cold metal tuning fork or tube	Suggests C-fibre involvement; seen in peripheral neuropathy
Temporal summation	Increasing pain with repetitive stimuli (wind-up)	Repeated pin-prick at 1 Hz over 30 seconds	Central sensitisation; predictor of treatment difficulty

Neurological Examination Findings

A focused examination should assess:

Sensory testing: Light touch (cotton wool), pin-prick, temperature (cold tuning fork or thermal rollers), vibration (128 Hz tuning fork on bony prominence), and joint position sense in a stocking-and-glove or dermatomal distribution.
Motor examination: Assess for weakness (suggests large-fibre involvement or motor neuropathy), e.g. foot drop in common peroneal neuropathy.
Reflexes: Diminished or absent ankle reflexes are an early sign of large-fibre diabetic neuropathy.
Autonomic features: Skin colour changes, temperature asymmetry, sweating abnormalities, oedema — particularly relevant in CRPS.

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Red flags requiring urgent investigation: Acute-onset severe neuropathic pain with progressive weakness (consider Guillain-Barré syndrome), saddle anaesthesia with bowel/bladder dysfunction (cauda equina syndrome), or unilateral facial pain with new cranial nerve signs (consider malignancy/vascular cause). These warrant immediate referral and neuroimaging.

Common Presentations by Aetiology

Condition	Typical Distribution	Key Features
Diabetic peripheral neuropathy	Stocking-and-glove, distal symmetric	Burning feet, nocturnal worsening, loss of ankle reflexes
Post-herpetic neuralgia	Dermatomal (thoracic > trigeminal)	Persistent pain > 3 months after acute herpes zoster; allodynia common
Trigeminal neuralgia	V2/V3 distribution (unilateral)	Brief electric-shock-like paroxysms triggered by touch, chewing, wind
CIPN	Stocking-and-glove (dose-dependent)	Numbness, tingling, burning; associated with platinum/taxane agents
CRPS	Single limb (distal)	Disproportionate pain, swelling, colour/temperature change, motor dysfunction after injury
Central post-stroke pain	Hemibody contralateral to lesion	Burning, dysaesthesia; onset weeks–months post-stroke

Screening Tools

Validated screening tools help differentiate neuropathic from nociceptive pain in primary care settings. While no single tool replaces a thorough clinical assessment, these instruments improve diagnostic accuracy and guide referral decisions.

Tool	Items	Scoring	Cut-off	Setting
DN4 (Douleur Neuropathique 4)	10 items (interview + exam)	0–10	≥ 4 = neuropathic pain likely	Primary care & specialist; most widely validated
painDETECT (PD-Q)	9 items (self-report)	0–38	≥ 19 = neuropathic; ≤ 12 = nociceptive; 13–18 = ambiguous	Primary care screening; no physical examination required
LANSS (Leeds Assessment of Neuropathic Symptoms and Signs)	7 items (5 symptoms + 2 clinical)	0–24	≥ 12 = neuropathic pain likely	Research and clinical; requires bedside sensory testing
NPQ (Neuropathic Pain Questionnaire)	12 items (self-report)	Algorithm-based	Score > 0 = neuropathic component	Clinical and research use
S-LANSS (Self-report LANSS)	7 items (self-report only)	0–24	≥ 12 = neuropathic pain likely	Telephone or remote screening; useful for telehealth

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Recommended in Australian practice: The DN4 is the most widely validated and recommended by Painaustralia for primary care screening. For telehealth consultations (increasingly relevant in rural/remote Australia), the self-report painDETECT or S-LANSS can be administered without physical examination. The MBS telehealth item numbers (e.g. 91800, 91801) support remote screening assessments.

When to Screen

All patients with diabetes presenting with new lower-limb pain or paraesthesiae.
Patients > 3 months post-herpes zoster with ongoing pain.
Cancer survivors completing neurotoxic chemotherapy (platinum agents, taxanes, vinca alkaloids, bortezomib).
Patients with persistent post-surgical pain (e.g. post-thoracotomy, post-mastectomy, post-inguinal hernia repair).
Patients with chronic low back pain who report shooting/radiating leg symptoms — to assess for radicular neuropathic component.

Quantitative Sensory Testing (QST)

QST is a specialist investigation available at major tertiary pain centres in Australia (e.g. Royal North Shore Hospital, Pain Management Research Institute – Sydney; Alfred Hospital – Melbourne). It objectively maps sensory thresholds and can differentiate between small-fibre and large-fibre dysfunction. QST is not routinely required for diagnosis but may assist in complex or medicolegal cases. Referral via MBS specialist consultation items (104, 105) may apply.

Pharmacological Adjuvants

Adjuvant analgesics are the mainstay of neuropathic pain pharmacotherapy. These agents were originally developed for other indications (depression, epilepsy) but have demonstrated efficacy in neuropathic pain through modulation of descending inhibitory pathways, sodium channel blockade, or reduction of central sensitisation. Australian Therapeutic Guidelines recommend a stepwise approach with monotherapy first, adequate trial duration (6–8 weeks at therapeutic dose), and combination therapy for refractory cases.

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Opioids are NOT first-line for neuropathic pain. Evidence does not support long-term opioid efficacy for neuropathic pain, and harms (dependence, opioid-induced hyperalgesia, falls in elderly, respiratory depression) outweigh benefits. If adjuvants fail, short-term opioid trial (≤ 4 weeks) may be considered with clear goals, exit strategy, and ongoing specialist oversight. Naloxone should be co-prescribed for patients on long-term opioids (PBS-listed naloxone injection is available).

First-Line Agents

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Amitriptyline

Endep® · Generic · Tricyclic antidepressant (TCA)

Mechanism Noradrenaline and serotonin reuptake inhibition; sodium channel blockade; NMDA antagonism

Adult dose Start 10 mg nocte, titrate by 10 mg weekly to 25–75 mg nocte (max 150 mg)

Paediatric dose 0.1–0.5 mg/kg nocte (specialist initiation recommended)

Renal adjustment Use with caution; no specific dose adjustment recommended

Hepatic adjustment Reduce dose in hepatic impairment; avoid in severe liver disease

Key side effects Anticholinergic (dry mouth, constipation, urinary retention), sedation, weight gain, QT prolongation, orthostatic hypotension

PBS status ✔ PBS General Benefit

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Duloxetine

Cymbalta® · Generic · Serotonin-noradrenaline reuptake inhibitor (SNRI)

Mechanism Serotonin and noradrenaline reuptake inhibition; enhances descending inhibitory pathways

Adult dose Start 30 mg mane for 1 week, then 60 mg mane (max 120 mg/day)

Paediatric dose Not established for neuropathic pain (TGA-approved from 7 years for GAD only)

Renal adjustment Avoid if eGFR < 30 mL/min

Hepatic adjustment Contraindicated in hepatic impairment

Key side effects Nausea (common in first 2 weeks), dry mouth, dizziness, fatigue, hypertension, hyponatraemia

PBS status ⚠️ PBS Authority Required — neuropathic pain where TCA contraindicated or not tolerated

Second-Line / Alternative First-Line Agents

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Pregabalin

Lyrica® · Generic · Gabapentinoid (α2δ ligand)

Mechanism Binds α2δ subunit of voltage-gated calcium channels; reduces excitatory neurotransmitter release

Adult dose Start 75 mg BD, titrate after 3–7 days to 150 mg BD (max 300 mg BD)

Paediatric dose Not established for neuropathic pain in children

Renal adjustment eGFR 30–60: max 75–150 mg BD; eGFR 15–30: 25–75 mg daily–BD; eGFR < 15: 25 mg daily

Hepatic adjustment No adjustment required (not hepatically metabolised)

Key side effects Dizziness, somnolence, peripheral oedema, weight gain, blurred vision

PBS status ⚠️ PBS Authority Required — neuropathic pain inadequately managed by TCA/SNRI

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Gabapentin

Neurontin® · Generic · Gabapentinoid (α2δ ligand)

Adult dose Start 300 mg nocte, titrate by 300 mg every 3–7 days to 300 mg TDS (max 3600 mg/day in divided doses)

Paediatric dose 5–10 mg/kg/day TDS, titrate to 25–40 mg/kg/day (specialist guidance)

Renal adjustment eGFR 30–60: 200–700 mg BD; eGFR 15–30: 200–700 mg daily; eGFR < 15: 100–300 mg daily

PBS status ⚠️ PBS Authority Required — neuropathic pain

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Carbamazepine

Tegretol® · Generic · Sodium channel blocker (iminostilbene)

Indication First-line for trigeminal neuralgia specifically

Adult dose Start 100 mg BD, titrate by 200 mg/day every 3–7 days to 200 mg TDS–QID (typical effective range 400–800 mg/day; max 1600 mg/day)

Renal adjustment No specific adjustment

Hepatic adjustment Contraindicated in severe hepatic impairment

Key side effects Dizziness, drowsiness, diplopia, SIADH, hyponatraemia, rash (including SJS — HLA-B*1502 testing in at-risk populations), bone marrow suppression

PBS status ✔ PBS General Benefit

Third-Line and Adjunctive Agents

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Oxcarbazepine

Trileptal® · Sodium channel blocker

Indication Alternative for trigeminal neuralgia if carbamazepine not tolerated

Adult dose Start 150 mg BD, titrate to 300–600 mg BD

PBS status ⚠️ PBS Authority Required

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Venlafaxine

Effexor-XR® · SNRI

Adult dose Start 37.5 mg daily, titrate to 150–225 mg daily

Note Evidence weaker than duloxetine; used when duloxetine not tolerated. Monitor BP.

PBS status ✔ PBS General Benefit (for depression; Authority Required for neuropathic pain indication)

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Lamotrigine

Lamictal® · Sodium channel blocker

Adult dose Start 25 mg daily for 2 weeks → 50 mg daily for 2 weeks → 100 mg daily (titrate slowly to reduce SJS risk)

Indication Central post-stroke pain; refractory cases with specialist guidance

PBS status ✔ PBS General Benefit (for epilepsy/bipolar; neuropathic pain is off-label)

Topical Agents

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Capsaicin 8% patch

Qutenza® · TRPV1 agonist (defunctionalisation)

Indication Peripheral neuropathic pain — especially post-herpetic neuralgia; diabetic peripheral neuropathy

Application Single 30-minute or 60-minute application by trained clinician; may repeat every 3 months

Setting Clinic-based (GP with appropriate facilities or pain clinic); requires topical anaesthetic pre-treatment

PBS status ✖ Not PBS-listed (cost approximately 0–450 per patch; some hospital outpatient pharmacies may supply under compassionate access)

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Lidocaine 5% patch

Versatis® · Local anaesthetic (sodium channel blocker)

Indication Localised peripheral neuropathic pain (PHN, post-surgical neuropathy)

Application Apply to intact skin over painful area for up to 12 hours on / 12 hours off

PBS status ✖ Not PBS-listed (self-funded; approximately –70 for 30 patches)

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Capsaicin 0.075% cream

Zacin® / Generic · TRPV1 agonist

Application Apply TDS–QID to affected area; onset over 1–2 weeks; initial burning may occur

PBS status ✔ PBS General Benefit

Recommended Treatment Algorithm

Step 1 — Monotherapy Trial

Start TCA (amitriptyline) or SNRI (duloxetine) at low dose. Titrate to therapeutic dose over 4–6 weeks. Trial for ≥ 6–8 weeks at target dose. For trigeminal neuralgia: carbamazepine first-line.

Step 2 — Switch or Add Gabapentinoid

If first agent inadequate/undertolerated, switch to alternative first-line or add pregabalin/gabapentin. Consider topical agents (lidocaine 5% patch, capsaicin) for localised pain.

Step 3 — Combination Therapy

Combine TCA/SNRI + gabapentinoid. Consider third-line agents (lamotrigine, venlafaxine, oxcarbazepine). Refer to multidisciplinary pain service if ≥ 2 agents have failed.

Step 4 — Specialist / Procedural Options

Multidisciplinary pain clinic referral. Procedural interventions (nerve blocks, spinal cord stimulation). Short-term opioid trial only under specialist supervision with exit strategy.

Procedural Options

Procedural interventions are reserved for patients with refractory neuropathic pain that has not responded to adequate pharmacological therapy (typically ≥ 2 adjuvant agents at therapeutic doses for ≥ 3 months each). These interventions are performed by pain medicine specialists, typically within a multidisciplinary pain service at an Australian hospital or specialist clinic.

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Referral threshold: Consider referral to a FPMANZCA (Faculty of Pain Medicine, ANZCA) accredited pain specialist when pain persists despite two adequate first- or second-line agents, or when pain is associated with significant functional impairment. Referral under Medicare via MBS specialist consultation items 104/105 or GP Management Plan items (721/723) with coordinated care.

Interventional Procedures

Procedure	Indication	Mechanism	Evidence Level	Australian Availability
Nerve blocks (local anaesthetic ± corticosteroid)	Localised peripheral neuropathic pain, PHN (intercostal, trigeminal), CRPS, ilioinguinal/iliohypogastric neuropathy	Interrupts nociceptive transmission; reduces peripheral sensitisation	Moderate (for PHN, CRPS)	Widely available; performed under ultrasound/fluoroscopy guidance in public and private settings
Pulsed radiofrequency (PRF)	Trigeminal neuralgia, occipital neuralgia, post-surgical neuropathy, radicular pain	Modulates nerve function without thermal destruction; reversible	Moderate (growing evidence)	Available at major pain centres; MBS item 18350 (radiofrequency lesion)
Spinal cord stimulation (SCS)	Failed back surgery syndrome, CRPS (types I & II), refractory peripheral neuropathic pain	Gate control theory; activates dorsal column Aβ fibres to inhibit pain transmission; newer high-frequency (HF10) and burst modes available	High (RCT evidence for CRPS, FBSS)	Available at tertiary centres (Royal North Shore, Alfred, Royal Adelaide, Fiona Stanley); trial period (5–7 days) before permanent implant; MBS item 18360
Intrathecal drug delivery	Severe refractory cancer and non-cancer neuropathic pain	Delivers low-dose opioids, local anaesthetic, ziconotide directly to spinal cord receptors	Moderate	Limited availability; tertiary centres only; significant cost and follow-up requirements
Botulinum toxin A (subcutaneous)	Peripheral neuropathic pain (PHN, painful diabetic neuropathy, post-traumatic neuropathy)	Inhibits release of CGRP, substance P, glutamate; reduces peripheral sensitisation	Moderate (multiple RCTs)	Off-label use; specialist initiation; Botox® or Dysport® — not PBS-subsidised for neuropathic pain
Sympathetic nerve blocks	CRPS (early intervention), sympathetically maintained pain	Interrupts sympathetic–nociceptive coupling	Moderate (for CRPS, best early)	Stellate ganglion block (upper limb) and lumbar sympathetic block (lower limb); available at major pain centres

Non-Pharmacological, Non-Procedural Therapies

These should be integrated at all stages of management and are essential for holistic care:

Cognitive-behavioural therapy (CBT) for pain: Addresses maladaptive pain beliefs, catastrophising, and avoidance behaviour. Available through publicly funded chronic pain programs and psychology services (MBS Better Access items 80100–80170 for up to 10 sessions per calendar year, with additional sessions available through GP Mental Health Treatment Plan).
Graded motor imagery and mirror therapy: Particularly effective for CRPS; sequential approach of laterality recognition → mirror therapy → graded exposure.
Transcutaneous electrical nerve stimulation (TENS): Gate control mechanism; self-administered; evidence is mixed but low-risk. Available without prescription; some state-based aids schemes provide funding.
Exercise therapy and physiotherapy: Graded aerobic exercise improves pain thresholds, mood, and function. Refer via GP Management Plan (MBS 721) and Team Care Arrangement (MBS 723) for up to 5 allied health sessions per year.
Mindfulness-based stress reduction (MBSR): Growing evidence for chronic pain management; group programs available through some hospital and community health services.

Monitoring

Ongoing monitoring is essential to assess treatment response, manage side effects, and adjust therapy. The following schedule is recommended:

Week 1–2

Initial follow-up: Assess tolerability, side effects, and medication adherence. Reinforce slow titration schedule. Check for anticholinergic effects (TCAs), nausea (duloxetine), or dizziness (gabapentinoids). Review suicidal ideation (all antidepressants — TGA black box warning applies).

Week 4–6

Titration review: Ensure target therapeutic dose has been reached. Re-administer DN4 or painDETECT to document baseline vs. current score. Assess functional improvement (return to work, sleep quality, mood).

Week 8–12

Efficacy assessment: Minimum 6-week trial at therapeutic dose before declaring treatment failure. If ≥ 30% pain reduction and functional improvement → continue. If inadequate → switch or add agent (Step 2 of algorithm). Arrange bloods if indicated (FBC for carbamazepine, EUC for gabapentinoids, LFTs for duloxetine/carbamazepine).

Month 3–6

Stabilisation phase: Review 3-monthly. Assess need for combination therapy or specialist referral. Monitor for weight gain (gabapentinoids, TCAs), metabolic effects, and drug interactions. Re-evaluate diagnosis if treatment is ineffective — consider alternative diagnoses (e.g. myelopathy, vascular claudication, fibromyalgia).

6–12 months

Long-term management: Consider dose reduction trial if pain well-controlled for ≥ 6 months. Monitor for opioid use if prescribed (urine drug screening, prescription monitoring via SafeScript/RTPM). Annual review of diagnosis, medication appropriateness, and psychological wellbeing.

Monitoring Investigations

Investigation	When	Rationale
FBC	Baseline + annually (carbamazepine: regular monitoring per PBS authority)	Carbamazepine: agranulocytosis, aplastic anaemia risk
EUC (sodium, renal function)	Baseline + 3-monthly for TCAs, carbamazepine	Hyponatraemia risk (carbamazepine, TCAs, duloxetine)
LFTs	Baseline (duloxetine, carbamazepine)	Hepatotoxicity risk
ECG	Before starting TCAs (if > 50 years, cardiac history, or dose > 100 mg)	QT prolongation and arrhythmia risk
HbA1c / glucose	If diabetic neuropathy suspected	Confirm diabetic aetiology; glycaemic control optimisation
B12, folate, TFTs	Baseline in new neuropathic pain presentations	Exclude reversible causes (B12 deficiency, hypothyroidism)

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Real-Time Prescription Monitoring (RTPM): All Australian states and territories now operate RTPM systems (e.g. SafeScript in Victoria, QScript in Queensland). If opioids or benzodiazepines are prescribed in the context of neuropathic pain management, prescribers must check the RTPM system before each prescription to identify patients at risk of harm from multiple supplier episodes or high-dose use.

Special Populations

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Pregnancy & Breastfeeding

Amitriptyline

Category C. Generally avoided in first trimester. Low doses (10–25 mg) may be used if benefits outweigh risks. Excreted in breast milk — monitor infant for sedation.

Duloxetine

Category B3. Avoid in third trimester (neonatal withdrawal syndrome). Not recommended during breastfeeding.

Pregabalin / Gabapentin

Category B3. Limited human data; avoid unless clearly indicated. Gabapentin preferred if gabapentinoid needed. Monitor neonate for withdrawal.

Carbamazepine

Category D. Teratogenic risk (neural tube defects ~1%). Supplement with folate 5 mg/day. If essential for trigeminal neuralgia, use lowest effective dose with specialist oversight.

Preferred approach

Non-pharmacological strategies first (TENS, physiotherapy, CBT). Paracetamol for nociceptive component. Lidocaine 5% patch (minimal systemic absorption) may be considered for localised pain.

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Paediatrics

General

Neuropathic pain in children is under-recognised. Common causes: CIPN, post-surgical pain, CRPS, phantom limb pain. Use validated paediatric pain tools (e.g. Paediatric painDETECT for ages ≥ 6 years).

Gabapentin

Most studied gabapentinoid in children. Start 5 mg/kg/day in 3 divided doses; titrate to 25–40 mg/kg/day. Available as oral liquid.

Amitriptyline

Used off-label in paediatric neuropathic pain. Start 0.1 mg/kg nocte; titrate slowly. Specialist initiation recommended. ECG monitoring if dose > 1 mg/kg.

Multidisciplinary approach

Refer to paediatric pain service (e.g. RCH Melbourne, CHW Sydney, PMH Perth). CBT and family-based interventions are first-line alongside pharmacotherapy.

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Elderly (> 65 years)

TCAs

Use with extreme caution. Anticholinergic burden increases fall risk, cognitive impairment, urinary retention, constipation. Amitriptyline listed on Beers Criteria as potentially inappropriate. Consider nortriptyline (less anticholinergic) at lower doses (10–25 mg nocte).

Duloxetine

Generally well-tolerated in elderly. May be preferred first-line over TCAs. Monitor for hyponatraemia (risk increases with age and concurrent diuretics/SSRIs).

Gabapentinoids

Start at lowest dose and titrate slowly. Dizziness and somnolence increase fall risk. Renal dose adjustment essential — eGFR declines with age. Pregabalin may cause peripheral oedema, worsening heart failure.

Key consideration

Review all medications for anticholinergic burden (use the Anticholinergic Cognitive Burden Scale). Polypharmacy is common; deprescribe where possible. Home Medicines Review (MBS 900) is recommended.

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Renal Impairment

Gabapentin

Significant renal dose reduction required (see dosing table above). Accumulates in renal failure causing excessive sedation and myoclonus.

Pregabalin

Requires dose reduction proportional to eGFR. Dose in milligrams, not milligrams per kilogram. See renal dosing in Adjuvants section.

Duloxetine

Avoid if eGFR < 30 mL/min.

Amitriptyline

No major renal adjustment but use cautiously — metabolites accumulate.

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Hepatic Impairment

Duloxetine

Contraindicated in hepatic impairment (hepatotoxicity risk). Choose alternative (gabapentin, pregabalin).

Carbamazepine

Hepatotoxic; avoid in severe liver disease. Monitor LFTs.

TCAs

Reduce dose in hepatic impairment; extensive hepatic metabolism.

Preferred agents

Gabapentin or pregabalin (not hepatically metabolised) are preferred in significant liver disease.

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Immunocompromised

HIV-associated neuropathy

Common with older antiretrovirals (dideoxynucleoside analogues). Treatment is the same as for other peripheral neuropathic pain. If ART-related, consider switching antiretroviral regimen in consultation with infectious disease specialist.

CIPN

Dose-dependent with platinum/taxane/vinca alkaloid agents. Duloxetine has best evidence for CIPN treatment. Prevention: no proven pharmacological agent (ice gloves/caps emerging evidence).

Post-transplant neuropathy

Calcineurin inhibitor toxicity may contribute. Monitor tacrolimus/ciclosporin levels. Drug interactions: carbamazepine induces CYP3A4 and reduces immunosuppressant levels — AVOID in transplant patients on calcineurin inhibitors.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of conditions causing neuropathic pain. Type 2 diabetes prevalence is 3–4 times higher than in non-Indigenous Australians (AIHW, 2023), driving significantly higher rates of diabetic peripheral neuropathy. Herpes zoster incidence is also elevated due to higher rates of immunosuppressive comorbidities. Pain management must be delivered in a culturally safe, trauma-informed manner that acknowledges historical and ongoing barriers to healthcare access.

Diabetes and diabetic neuropathy

Type 2 diabetes affects approximately 8% of Aboriginal and Torres Strait Islander adults (age-standardised), with onset at younger ages. Diabetic peripheral neuropathy screening should be integrated into Indigenous Health Checks (MBS 715). Annual foot assessments by a podiatrist (funded through state/territory programs or Closing the Gap PBS co-payment measure) are essential for early detection.

Access to specialist services

Pain medicine specialists and multidisciplinary pain clinics are concentrated in major metropolitan centres. Aboriginal and Torres Strait Islander people in rural and remote areas may have limited access. Telehealth (MBS items 91800, 91801, 91802) can facilitate specialist consultation. Aboriginal Health Workers and Practitioners (AHWPs) should be supported to deliver neuropathic pain screening and basic pharmacological management with appropriate training.

Cultural safety and pain expression

Pain expression may be influenced by cultural factors. Some Aboriginal and Torres Strait Islander people may minimise or differently describe neuropathic symptoms. Clinicians should use culturally appropriate screening tools and allow time for storytelling-based consultations. Ensure interpreter services are available where English is not the first language.

Post-herpetic neuralgia

Shingles vaccination (Zostavax® — funded under NIP for eligible adults ≥ 65; Shingrix® recommended from 50 years) coverage remains lower in Aboriginal and Torres Strait Islander communities. Acyclovir/valaciclovir for acute herpes zoster should be initiated within 72 hours of rash onset (PBS-listed). Ensure supply in remote clinics via CARPA Standard Treatment Manual or equivalent.

Medication access (Closing the Gap PBS Co-Payment)

Under the Closing the Gap PBS Co-Payment Program, eligible Aboriginal and Torres Strait Islander patients pay a reduced or nil co-payment for PBS-listed medicines. This applies to gabapentin, pregabalin, amitriptyline, duloxetine, carbamazepine, and capsaicin 0.075% cream. Remote area Aboriginal Health Services can supply medicines under Section 100 arrangements. Ensure scripts are written clearly and that PBS Authority approvals are obtained in a timely manner.

Methadone and buprenorphine programs

In communities where opioid dependence co-exists with chronic pain (including neuropathic pain), buprenorphine-naloxone (Suboxone®) or methadone may serve dual roles. Specialist addiction medicine and pain medicine collaboration is essential. Opioid Treatment Program prescribers should have training in chronic non-cancer pain assessment.

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Recommended actions for primary care: Incorporate neuropathic pain screening into routine Indigenous Health Checks (MBS 715). Use the DN4 tool and document results. Ensure first-line medications are available through the Closing the Gap PBS Co-Payment. Arrange telehealth pain specialist consultation if ≥ 2 adjuvants fail. Engage Aboriginal Health Workers in patient education about pain neuroscience and self-management strategies. Refer to Painaustralia's Indigenous pain resources and the Indigenous Allied Health Australia (IAHA) network.

📚 References

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5. Painaustralia. National Strategic Action Plan for Pain Management. Canberra: Painaustralia; 2019.
6. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
7. Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. 2010;85(3 Suppl):S3-S14.
8. Moisset X, Bouhassira D, Avez Couturier J, et al. Pharmacological and non-pharmacological treatments for neuropathic pain: systematic review and French recommendations. Rev Neurol (Paris). 2020;176(5):325-352.
9. Cruccu G, Di Stefano G, Truini A. Trigeminal neuralgia. N Engl J Med. 2020;383(8):754-762. doi:10.1056/NEJMra1914484
10. Harden RN, Bruehl S, Perez RSGM, et al. Validation of proposed diagnostic criteria (the "Budapest Criteria") for complex regional pain syndrome. Pain. 2010;150(2):268-274.
11. Mücke M, Phillips T, Radbruch L, Petzke F, Häuser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018;3(3):CD012182.
12. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (FPMANZCA). Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain. Melbourne: ANZCA; 2022.
13. Therapeutic Goods Administration (TGA). Prescription medicines: new or extended uses, or new combinations of registered medicines. Canberra: Department of Health and Aged Care; 2023.
14. CARPA. Central Australian Rural Practitioners Association Standard Treatment Manual. 7th ed. Alice Springs: CARPA; 2017.
15. Bates D, Schultheis BC, Hanes MC, et al. A comprehensive algorithm for management of neuropathic pain. Pain Med. 2019;20(Suppl 1):S2-S12.
16. Gibson W, Arendt-Nielsen L, Graven-Nielsen T. Reappraisal of the clinical relevance of temporal summation of pain in neuropathic and nociceptive pain conditions. Scand J Pain. 2021;21(2):213-221.

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).