Renal Colic Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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NSAIDs are first-line analgesia for renal colic — IV diclofenac 75 mg or IM ketorolac 30 mg provide superior ureteric smooth-muscle relaxation and pain relief compared with opioids.
NSAIDs and opioids have similar analgesic efficacy in renal colic, but NSAIDs reduce ureteric spasm and are therefore preferred as initial therapy.
IV paracetamol monotherapy is inferior to NSAIDs for renal colic; however, IV paracetamol 1 g is a useful adjunct when NSAIDs are contraindicated or as part of multimodal analgesia.
Opioids (morphine or oxycodone) are second-line agents reserved for refractory pain, NSAID contraindications, or as bridging therapy pending specialist review.
Intravenous route is preferred in acute severe presentations (VAS ≥ 7/10); intramuscular ketorolac is an effective alternative when IV access is difficult. Oral NSAIDs suit mild–moderate pain and discharge analgesia.
Alpha-blockers (tamsulosin) are medical expulsive therapy for ureteric stones ≤ 10 mm — they do NOT treat acute pain and must not be substituted for analgesia.
Ketorolac is PBS-listed for acute pain in Australia (Authority Required for IV use); diclofenac IM/IV is also available on the PBS for acute musculoskeletal and renal pain.
Renal dose adjustments are critical — avoid NSAIDs in eGFR < 30 mL/min/1.73 m²; reduce opioid doses in renal impairment (avoid morphine active metabolites, prefer oxycodone or fentanyl).
Antiemetics (ondansetron 4 mg IV or metoclopramide 10 mg IV) should be co-administered as nausea and vomiting are present in > 50% of renal colic presentations.
Aboriginal and Torres Strait Islander Australians have higher rates of renal calculi presentation; consider remote access limitations, language barriers, and cultural safety in analgesia planning.
Reassess pain within 30 minutes of parenteral analgesia; escalate to second-line agents or urological referral if pain remains severe despite multimodal therapy.
Always exclude red flags (urosepsis, complete obstruction, solitary kidney) before discharge — these require urgent urological intervention, not outpatient analgesia alone.

Introduction & Australian Epidemiology

Renal colic is one of the most severe acute pain syndromes encountered in emergency medicine and primary care. The pain arises from acute ureteral obstruction — most commonly by a calculus — causing distension of the renal capsule, ureteric spasm, and release of prostaglandins and inflammatory mediators. Patients frequently describe the pain as the worst they have ever experienced, often exceeding that of fractures or myocardial infarction on visual analogue scales.

In Australia, the lifetime prevalence of urolithiasis is approximately 10–15%, with an annual incidence of around 150 per 100,000 population. Males are affected twice as commonly as females, and peak incidence occurs between ages 30 and 60 years. Australian data from the AIHW indicate that urinary calculi account for over 80,000 emergency department presentations annually, representing a significant healthcare burden.

Climate and geography play important roles in Australia. The prevalence of renal calculi is notably higher in tropical and subtropical regions (Northern Territory, Far North Queensland) due to chronic dehydration and heat stress. Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of renal calculi and related complications, compounded by barriers to timely healthcare access in remote communities.

Effective analgesia is the cornerstone of initial management. The choice of agent, route, and timing significantly influences patient comfort, emergency department length of stay, and the success of a trial-of-passage strategy for small stones. This article reviews the evidence-based analgesic options for acute renal colic in the Australian clinical context.

⚠️

Do not confuse medical expulsive therapy with analgesia. Alpha-blockers (tamsulosin) facilitate stone passage but have no acute analgesic effect. All patients with renal colic require appropriate analgesia regardless of whether expulsive therapy is commenced.

NSAIDs

Non-steroidal anti-inflammatory drugs are first-line analgesia for acute renal colic. They work by inhibiting cyclooxygenase (COX-1 and COX-2), reducing prostaglandin synthesis in the renal pelvis and ureter. This decreases ureteric smooth-muscle spasm, reduces oedema at the site of obstruction, and lowers intrapelvic pressure — providing both analgesic and antispasmodic benefit that opioids cannot offer.

Multiple systematic reviews and meta-analyses (Cochrane 2015, Pathan et al. 2018) demonstrate that NSAIDs provide equivalent or superior analgesia to opioids for renal colic, with fewer adverse effects including less nausea, vomiting, and sedation. Australian Therapeutic Guidelines recommend NSAIDs as the initial analgesic of choice for renal colic.

First-Line NSAID Agents

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Diclofenac Sodium

Voltaren® · Dyloject® · Generic · Non-selective NSAID

Adult dose 75 mg IM (deep gluteal) or 75 mg IV (over 2–5 min); may repeat once after 30 min if needed. Max 150 mg/24 h. Oral 50 mg TDS PRN for discharge.

Paediatric dose 1 mg/kg IV (max 75 mg) for adolescents ≥ 12 years; limited data in younger children — consult paediatric guidelines.

Renal adjustment Avoid if eGFR < 30 mL/min/1.73 m²; use with caution if eGFR 30–60; monitor fluid status.

Hepatic adjustment Avoid in severe hepatic impairment (Child-Pugh C); dose-reduce in moderate impairment.

PBS status ✔ PBS General Benefit (oral 50 mg) Authority Required (IV/IM — hospital use)

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Ketorolac Trometamol

Toradol® · Generic · Potent non-selective NSAID

Adult dose 30 mg IM or 30 mg IV (over 15 sec); may give 15–30 mg after 6 h PRN. Max 90 mg/day (60 mg/day if age > 65 or weight < 50 kg). Duration ≤ 5 days.

Paediatric dose 0.5 mg/kg IM/IV (max 15 mg) for adolescents ≥ 16 years. Not routinely recommended in younger children.

Renal adjustment Contraindicated if eGFR < 30 mL/min/1.73 m². Reduce dose and duration if eGFR 30–60.

Hepatic adjustment Avoid in significant hepatic impairment; risk of GI bleeding increased.

PBS status Authority Required (parenteral — hospital use) ✔ PBS General Benefit (oral 10 mg)

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Ibuprofen

Nurofen® · Brufen® · Generic · Non-selective NSAID

Adult dose 400–600 mg PO TDS–QDS with food. Max 2.4 g/day for acute use. IV ibuprofen ( Caldolor® ) 400–800 mg every 6 h where available.

Paediatric dose 5–10 mg/kg PO TDS (max 40 mg/kg/day) for children ≥ 3 months.

Renal adjustment Avoid if eGFR < 30 mL/min/1.73 m².

PBS status ✔ PBS General Benefit

NSAID Contraindications & Precautions

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Absolute contraindications to NSAIDs in renal colic:

eGFR < 30 mL/min/1.73 m² (risk of acute kidney injury)
Active GI bleeding or peptic ulcer disease
Known hypersensitivity to aspirin or any NSAID (including history of NSAID-exacerbated respiratory disease)
Third trimester of pregnancy (risk of premature ductus arteriosus closure and oligohydramnios)
Severe hepatic impairment (Child-Pugh C)
Concurrent anticoagulation with active bleeding
Coronary artery bypass graft (CABG) perioperative period

Comparative Efficacy — NSAIDs vs Opioids in Renal Colic

Parameter	NSAIDs	Opioids
Analgesic onset	15–30 min (IV/IM)	5–10 min (IV)
Peak effect	30–60 min	15–20 min
Duration of relief	6–8 hours	2–4 hours
Mechanism of benefit	Analgesic + antispasmodic (↓ prostaglandins, ↓ ureteric oedema)	Central analgesic only (no effect on ureteric spasm)
Nausea/vomiting rate	Low (~5%)	Moderate–High (15–30%)
Respiratory depression	None	Dose-dependent risk
Renal risk	Significant if eGFR < 60	Minimal direct renal risk (but metabolite accumulation)
Level of evidence	Multiple RCTs and Cochrane meta-analysis — first-line	Established efficacy, recommended as second-line

Opioids

Opioids are the second-line analgesic class for renal colic, indicated when NSAIDs are contraindicated, insufficient as monotherapy, or when rapid-onset analgesia is needed as a bridge while awaiting NSAID effect. They act on μ-opioid receptors in the central and peripheral nervous system to modulate pain perception. Importantly, opioids do not address the underlying pathophysiology of ureteric spasm and may cause nausea, vomiting, constipation, respiratory depression, and — in the case of morphine — accumulation of active metabolites in renal impairment.

Opioid Agents

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Morphine Sulfate

Ordine® · Generic · μ-opioid agonist

Adult dose 2.5–5 mg IV (diluted, titrated every 5–10 min); or 0.1 mg/kg IM. Oral 5–10 mg every 4 h PRN for ongoing pain.

Paediatric dose 0.1–0.2 mg/kg IV (max 5 mg per dose) titrated; or 0.1–0.2 mg/kg IM.

Renal adjustment Avoid in eGFR < 30 — active metabolite (M6G) accumulates, causing prolonged sedation and respiratory depression. Use fentanyl or oxycodone with caution instead.

Hepatic adjustment Reduce dose by 50% in severe hepatic impairment; titrate cautiously.

PBS status ✔ PBS General Benefit (oral liquid, tablets) Authority Required (parenteral — hospital use)

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Oxycodone

Endone® · OxyNorm® · Generic · μ-opioid agonist

Adult dose 2.5–5 mg PO every 4–6 h PRN; titrate to effect. Max 20 mg per dose in opioid-naïve patients. No widely available parenteral formulation in Australian EDs (use morphine or fentanyl IV).

Paediatric dose 0.1–0.2 mg/kg PO every 4–6 h (max 5 mg per dose). Use in adolescents ≥ 12 years with caution.

Renal adjustment Reduce dose by 50% if eGFR 10–30; avoid if eGFR < 10. Safer than morphine in moderate renal impairment (no active metabolite accumulation at M6G levels).

Hepatic adjustment Start at lowest dose in hepatic impairment; extended half-life.

PBS status ✔ PBS General Benefit

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Fentanyl

Sublimaze® · Generic · Synthetic μ-opioid agonist

Adult dose 25–50 mcg IV titrated every 3–5 min; onset 1–2 min. Intranasal (IN) fentanyl 1.5 mcg/kg (max 100 mcg) where IV access is delayed. Duration 30–60 min.

Paediatric dose 0.5–1 mcg/kg IV titrated; IN 1.5 mcg/kg (max 100 mcg). Preferred opioid in children due to rapid offset and less histamine release.

Renal adjustment No dose adjustment required — preferred opioid in renal impairment (no active metabolites).

Hepatic adjustment Use with caution; highly hepatically metabolised. Prolonged effect in severe liver disease.

PBS status Authority Required (parenteral — hospital use) Authority Required (intranasal — hospital/specialist)

⚠️

Opioid safety — always co-prescribe antiemetics. Opioid-induced nausea occurs in 15–30% of patients. Pre-treat with ondansetron 4 mg IV/ODT or metoclopramide 10 mg IV. Monitor respiratory rate and sedation score (RASS) after parenteral opioids. Ensure naloxone is immediately accessible in all clinical settings where parenteral opioids are administered.

Opioid Cautions in Renal Colic

Morphine is best avoided in renal impairment (eGFR < 30) due to accumulation of morphine-6-glucuronide (M6G) causing delayed respiratory depression, excessive sedation, and myoclonus.
Fentanyl is the preferred opioid in renal impairment — it has no active metabolites and predictable pharmacokinetics.
Tramadol is not recommended as first-line for renal colic — lower efficacy than morphine, higher nausea rates, seizure risk, and active metabolite accumulation in renal impairment.
Codeine is not recommended — unreliable metabolism (CYP2D6 polymorphism), constipation, and poor efficacy for visceral pain syndromes.
Avoid long-acting or modified-release opioids in the acute setting; use immediate-release formulations titrated to effect.

Paracetamol

Paracetamol (acetaminophen) is the most widely used analgesic in Australia and is commonly administered for acute pain in emergency departments. However, evidence for its efficacy in renal colic as monotherapy is limited. A Cochrane review and subsequent RCTs have shown that IV paracetamol provides inferior analgesia compared with IV NSAIDs for renal colic. Its role is therefore primarily as an adjunctive agent within a multimodal analgesic strategy rather than as a first-line standalone treatment.

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Paracetamol (Acetaminophen)

Panadol® · Panamax® · Dymadon® · Generic

Adult dose — IV 1 g IV infusion over 15 min, every 4–6 h. Max 4 g/day (2 g/day if weight < 50 kg or hepatic impairment).

Adult dose — Oral 1 g PO every 4–6 h PRN. Max 4 g/24 h.

Paediatric dose 15 mg/kg IV every 4–6 h (max 60 mg/kg/day, max single dose 1 g). Oral: 15 mg/kg every 4–6 h.

Renal adjustment No adjustment required at standard doses; safe in all stages of CKD. Preferred base analgesic in renal impairment.

Hepatic adjustment Reduce max dose to 2 g/day in severe hepatic impairment or chronic liver disease; avoid in active fulminant hepatic failure.

PBS status ✔ PBS General Benefit (oral) Authority Required (IV — hospital use)

When to Use Paracetamol in Renal Colic

Adjunctive Use

Multimodal Analgesia

Add IV or oral paracetamol to an NSAID regimen to enhance overall pain control. This is the most evidence-supported role for paracetamol in renal colic.

Setting: ED, short-stay unit, or post-procedural

Alternative Base

NSAID-Contraindicated Patients

When NSAIDs are contraindicated (eGFR < 30, GI bleeding, pregnancy third trimester, allergy), paracetamol serves as the base analgesic — combine with opioid for moderate–severe pain.

Setting: ED or inpatient

Discharge

Ongoing Analgesia

Prescribe paracetamol 1 g QDS PRN as the baseline analgesic at discharge, with short-course oral NSAIDs (if tolerated) and/or oral opioids for breakthrough pain.

Setting: Post-ED discharge or outpatient

ℹ️

Evidence summary: A 2018 meta-analysis (Pathan et al., Annals of Emergency Medicine) demonstrated that IV paracetamol alone achieved significantly less pain reduction at 30 minutes compared with IV ketorolac or IV diclofenac in renal colic (mean VAS difference –1.7 points in favour of NSAIDs). Paracetamol should therefore not be used as the sole analgesic in moderate–severe renal colic.

Route Selection

The choice of analgesic route in renal colic depends on pain severity, the clinical setting, patient factors (ability to tolerate oral intake, IV access), and time since last oral intake. Renal colic pain is often severe at presentation (VAS ≥ 7/10), making the parenteral route the default initial approach in emergency settings.

Route Decision Algorithm

Assess Pain Severity (VAS / NRS)

Use a validated 0–10 numeric rating scale. Severe pain (≥ 7/10) warrants parenteral analgesia. Mild–moderate (3–6/10) may be managed with oral agents if the patient can tolerate oral intake.

Severe Pain — Parenteral Route Preferred

IV access available: IV diclofenac 75 mg or IV ketorolac 30 mg (first-line). If inadequate after 30 min, add IV fentanyl 25–50 mcg or IV morphine 2.5–5 mg. Co-administer IV ondansetron 4 mg if nauseated. No IV access: IM diclofenac 75 mg or IM ketorolac 30 mg. Consider intranasal fentanyl 1.5 mcg/kg (max 100 mcg) for rapid analgesia while arranging access.

Mild–Moderate Pain — Oral Route

Oral ibuprofen 400–600 mg with food or oral diclofenac 50 mg, combined with paracetamol 1 g. Suitable for patients presenting to primary care or being discharged from ED. Add oral oxycodone 2.5–5 mg for breakthrough if needed.

Reassess at 30 Minutes

If pain remains ≥ 7/10 after initial parenteral NSAID, escalate: add opioid, repeat NSAID dose (if within limits), and consider admission or urological referral. Document pain scores before and after each intervention.

Route Comparison Summary

Route	Onset	Best For	Limitations
Intravenous (IV)	2–5 min	ED presentations; severe pain; unable to tolerate oral	Requires IV cannulation; hospital setting
Intramuscular (IM)	10–15 min	No IV access; prehospital; rural/remote settings	Painful injection; slower peak; limited re-dosing
Intranasal (IN)	5–10 min	Bridge analgesia (IN fentanyl); children; needle-averse	Limited agents; dose constraints; nasal congestion
Oral (PO)	30–60 min	Mild–moderate pain; discharge analgesia; GP presentations	Nausea/vomiting may impair absorption; slower onset
Rectal (PR)	15–30 min	Vomiting patients; no IV access; prehospital	Patient acceptance variable; erratic absorption

✅

Multimodal analgesia is best practice. Combine paracetamol + NSAID (unless contraindicated) ± opioid for moderate–severe pain. Multimodal regimens reduce total opioid consumption, decrease adverse effects, and improve patient satisfaction. Example ED protocol: IV diclofenac 75 mg + IV paracetamol 1 g + IV ondansetron 4 mg simultaneously.

Special Populations

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Pregnancy

First-line: IV paracetamol 1 g every 6 h (safe in all trimesters).

Second-line (1st–2nd trimester only): Oral ibuprofen or diclofenac — avoid from 28 weeks (risk of premature ductus arteriosus closure and oligohydramnios).

Opioids: Morphine or fentanyl at reduced doses may be used short-term for severe pain. Avoid codeine (excreted in breast milk; neonatal respiratory depression risk).

Note: Renal colic in pregnancy requires obstetric review. NSAIDs are contraindicated in the third trimester. Always confirm pregnancy status in women of childbearing age before administering NSAIDs. Imaging with low-dose CT or ultrasound avoids ionising radiation.

👶

Paediatrics

First-line: IV paracetamol 15 mg/kg (max 1 g) + IV ibuprofen 5–10 mg/kg (max 400 mg).

Second-line: IV fentanyl 0.5–1 mcg/kg titrated (preferred opioid in children — rapid offset, less histamine release).

Intranasal: IN fentanyl 1.5 mcg/kg (max 100 mcg) for needle-averse children or difficult IV access.

Note: Renal calculi in children are uncommon — always investigate underlying metabolic or anatomical causes (hypercalciuria, renal tubular acidosis, structural anomalies). Refer to paediatric nephrology or urology.

👴

Elderly (≥ 65 years)

NSAIDs: Use lowest effective dose for shortest duration. Ketorolac max 15 mg per dose (half standard dose if age > 65). Avoid if eGFR < 30. Monitor renal function.

Opioids: Reduce initial dose by 50%; titrate slowly. Monitor for delirium, falls, constipation, urinary retention. Fentanyl preferred in CKD.

Paracetamol: No dose adjustment — safe as baseline analgesic. Consider hepatic function if frail.

Note: Elderly patients are at higher risk of NSAID-related GI bleeding and AKI. Consider PPI co-prescription (e.g., pantoprazole 40 mg IV/OD) if NSAIDs are used. Assess hydration status carefully.

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Renal Impairment

eGFR 30–60: NSAIDs may be used short-term with caution; ensure adequate hydration; recheck renal function.

eGFR < 30: Avoid NSAIDs entirely. Base analgesia on IV paracetamol + fentanyl (no active metabolites). Morphine is contraindicated (M6G accumulation).

Dialysis: Paracetamol safe. Fentanyl is preferred opioid. Avoid morphine and codeine. NSAIDs absolutely contraindicated.

Note: A single kidney, bilateral obstruction, or obstructed solitary kidney constitutes a urological emergency — urgent decompression required regardless of analgesia plan.

🛡️

Immunocompromised

Standard analgesic regimens apply. However, lower threshold for imaging and urological referral — infected hydronephrosis (pyonephrosis) in immunocompromised patients carries high mortality and requires urgent decompression.

Monitor closely for signs of urosepsis (fever, rigors, haemodynamic instability) which may be masked by anti-inflammatory effects of NSAIDs.

Note: Consider HIV-related renal disease, BK nephropathy in transplant recipients, and drug-induced nephrolithiasis (e.g., indinavir stones, triamterene stones) as differential diagnoses.

Aboriginal and Torres Strait Islander Health

Epidemiology

Aboriginal and Torres Strait Islander Australians have a significantly higher burden of renal calculi and urinary tract disease compared with non-Indigenous Australians. AIHW data show age-standardised hospitalisation rates for urolithiasis are 1.5–2 times higher in Indigenous Australians, with a higher proportion of complicated presentations including infected obstructive uropathy and renal failure.

Remote & Rural Access

Many Indigenous Australians live in remote and very remote communities where access to IV medications, imaging (CT), and urological specialist services is limited or delayed by hours to days. In these settings, IM ketorolac 30 mg or IM diclofenac 75 mg is the most practical first-line analgesic. Oral ibuprofen 400 mg with paracetamol 1 g can be used for mild–moderate presentations. Arrange retrieval to a regional centre if pain is refractory, fever develops, or there is suspicion of complicated stone disease.

Cultural Safety

Engage Aboriginal and Torres Strait Islander health workers and liaison officers early in the patient journey. Pain expression may differ culturally — avoid assumptions about pain severity based on verbal report alone. Use visual pain assessment tools where language barriers exist. Ensure informed consent for procedures (e.g., IV cannulation, ureteric stenting) is obtained in a culturally appropriate manner.

Prevention & Follow-Up

Hydration is a critical modifiable risk factor, particularly in hot climates. Community health programmes should promote adequate fluid intake, reduce sugar-sweetened beverage consumption (linked to higher stone risk), and ensure timely follow-up after acute episodes. Renal calculi analysis and metabolic workup should be offered to all Indigenous patients with recurrent stones to identify treatable causes.

Comorbidity Considerations

High rates of concurrent chronic kidney disease (CKD), diabetes mellitus, and cardiovascular disease in Indigenous Australians affect analgesic choice. NSAIDs must be used with extra caution in patients with pre-existing CKD — check eGFR before prescribing. Ensure that all analgesic plans account for existing medications (e.g., ACE inhibitors + NSAIDs = triple whammy nephrotoxicity risk if dehydrated).

📚 References

1. Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Annals of Emergency Medicine. 2018;71(1):51–61.
2. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database of Systematic Reviews. 2005;(2):CD004137. Updated 2015.
3. Afshar K, Jafari S, Marks AJ, Eftekhari A, MacNeily AE. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database of Systematic Reviews. 2015;(6):CD006027.
4. Royal Australian College of General Practitioners (RACGP). Guideline for the management of kidney stones in primary care. East Melbourne: RACGP; 2022.
5. Urological Society of Australia and New Zealand (USANZ). Guidelines for acute management of first-time renal colic. Sydney: USANZ; 2021.
6. Australian Institute of Health and Welfare (AIHW). Kidney disease in Aboriginal and Torres Strait Islander people. Canberra: AIHW; 2023.
7. Campschroer T, Zhu X, Duijvesz D, Grobbee DE, Lock MTWT. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database of Systematic Reviews. 2014;(4):CD008509.
8. Worster AS, Bhanich Supapol W, et al. Ketorolac versus morphine for acute renal colic: a systematic review. CJEM. 2012;14(2):90–98.
9. Pharmaceutical Benefits Scheme (PBS). Schedule of Pharmaceutical Benefits. Australian Government Department of Health and Aged Care. Canberra; 2024. Available at: pbs.gov.au.
10. Turk C, Neisius A, Petrik A, et al. EAU Guidelines on Urolithiasis. European Association of Urology; 2023.
11. Fan J, et al. Comparison of intravenous paracetamol versus intramuscular diclofenac for acute renal colic: a randomised controlled trial. Emergency Medicine Australasia. 2020;32(5):767–774.
12. Lee A, et al. Pain management strategies for renal colic in Australian emergency departments: a national survey. Emergency Medicine Australasia. 2021;33(3):452–459.
13. RHDAustralia (Rheumatic Heart Disease Australia). Clinical guidelines for the management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020. [Referenced for ATSI health equity framework].
14. Trauma and Orthopaedic Guidelines, Australian and New Zealand Society of Nephrology (ANZSN). Guideline for medication dosing in renal impairment. Nephrology. 2023;28(S1):1–42.

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

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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.
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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).