Do you refer a patient to rheumatology for osteoporosis and a lumbar fracture?

Referral to Rheumatology for Osteoporosis and Lumbar Fracture

Most patients with osteoporosis and a lumbar fracture do NOT require rheumatology referral and should be managed by primary care or endocrinology, with rheumatology reserved only for complex cases involving underlying inflammatory disease or treatment failure. 1

When Rheumatology Referral is NOT Indicated

The majority of osteoporosis cases, even with fracture, should be managed without rheumatology involvement:

• Glucocorticoid-induced osteoporosis is not unique to rheumatology and is widely managed by primary care providers and other subspecialists 1
• Standard osteoporosis with fragility fracture should be referred to endocrinology or an osteoporosis specialist, NOT rheumatology 1
• Primary care can appropriately manage most osteoporosis cases with calcium, vitamin D, and bisphosphonates 1

Specific Criteria for Specialist Referral (Endocrinology Preferred)

Refer to an osteoporosis specialist (clinical endocrinologist) or fracture liaison team for the following situations 1:

• Recurrent fractures or continued bone loss while receiving therapy without obvious treatable causes 1
• Unexpectedly low BMD or unusual features such as young age, unexplained artifacts on bone density tests, or abnormal laboratory studies (high or low alkaline phosphatase, low phosphorus) 1
• Premenopausal women or men under 50 with fragility fractures, as the majority have underlying disease requiring specialized evaluation 1
• Osteoporosis with complicating conditions such as decreased kidney function, hyperparathyroidism, or malabsorption 1
• Metabolic bone disease affecting bone health (hyperthyroidism, hyperparathyroidism, hypercalciuria, elevated prolactin) 1

When Rheumatology Referral IS Appropriate

Rheumatology referral is specifically indicated only when:

• Underlying inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis) is suspected or confirmed as the cause of osteoporosis 1
• Active autoimmune disease requiring disease-modifying antirheumatic drugs that affect bone metabolism 2, 3
• Connective tissue diseases are present alongside osteoporosis 1
• Complex glucocorticoid-dependent inflammatory conditions requiring shared care between rheumatology and primary care 1

Practical Management Algorithm

For a patient with osteoporosis and lumbar fracture:

1. Primary care should initiate workup including DXA scan, FRAX calculation, laboratory evaluation for secondary causes (CBC, CMP, 25-OH vitamin D, TSH, calcium, phosphorus, alkaline phosphatase), and vertebral fracture assessment 1, 4

2. Start treatment immediately with calcium (1000-1200 mg daily), vitamin D (600-800 IU daily targeting 25-OH vitamin D ≥30 ng/mL), and oral bisphosphonates for high-risk patients 1, 4

3. Refer to endocrinology (not rheumatology) if any specialist criteria above are met 1

4. Consider rheumatology only if inflammatory arthritis or autoimmune disease is suspected based on joint symptoms, elevated inflammatory markers, or positive autoantibodies 1, 2

Common Pitfalls to Avoid

• Do not reflexively refer osteoporosis to rheumatology simply because it involves bones and joints—this is not a rheumatologic disease unless inflammatory arthritis is present 1
• Do not delay treatment waiting for specialist referral; primary care should initiate calcium, vitamin D, and bisphosphonates immediately for appropriate candidates 4, 5
• Do not overlook secondary causes of osteoporosis that may require endocrinology rather than rheumatology expertise 1
• Recognize that a mandatory rheumatology consult for hip fractures increased treatment rates from 23% to 96% in one institution, but this was for treatment initiation, not ongoing rheumatologic disease management 5