Osteoporosis and metabolic bone disease

​​​​​​​Emergency

If any of the following are suspected, seek emergency medical advice or refer the patient to the emergency department (via ambulance if necessary)

  • Acute anterior uveitis on bisphosphonates (e.g. erythema, photophobia, blurred vision)
    Note: urgent ophthalmology assessment is indicated
  • Acute, severe hypophosphatemia
  • Radiologically suspected or confirmed atypical femoral fracture
    Note: subsequent endocrinology or rheumatology review may be indicated
  • Severe, symptomatic hypocalcaemia (albumin-corrected serum calcium < 1.9 mmol/L) due to metabolic bone disease or its treatment (e.g. denosumab-related, hypoparathyroidism such as post-thyroidectomy or spontaneous, severe vitamin D deficiency)
  • Severe, symptomatic hypercalcaemia (albumin-corrected serum calcium > 3.0 mmol/L) due to metabolic bone disease or its treatment (e.g. hyperparathyroidism, vitamin D toxicity, teriparatide therapy)
  • Vertebral fracture following delay or recent discontinuation of denosumab
    Note: refer to neurosurgery if neurological symptoms
  • Vertebral fracture with severe pain or signs of neurological compromise

When public outpatient services are not routinely provided

  • Acute fracture requiring orthopaedic intervention
  • Loss of height without further investigation
    Note: in line with RACGP guidelines, patients with asymptomatic loss of height should be referred for a vertebral x-ray to assess for a vertebral fracture
  • Low fracture risk (low risk on fracture risk calculator e.g. FRAX or Garvan Fracture Risk Calculator) and no history of minimal trauma fracture
    Note: consider using the Healthy Bones Australia – Osteoporosis Risk Assessment, Diagnosis and Management flow chart
  • Pathological fracture due to known malignancy (e.g. secondary to metastatic bone disease)
    Note: referral to treating cancer specialist or emergency department, as appropriate, is indicated
  • Recurrent falls without fracture
    Note: referral to falls prevention program or appropriate speciality (e.g. neurology, geriatric medicine)
  • Secondary fracture prevention where osteoporosis is suspected
    Note: consider referral to Osteoporotic Refracture Prevention service, where available
  • Severe bone pain or deformity related to osteoarthritis or inflammatory arthritis

Criteria to access public outpatient services

CategoryCriteria
Category 1
Recommended to be seen within 30 calendar days.
  • Atypical femoral fractures for ongoing management of osteoporosis
    Note: consider concurrent referral to orthopaedics for fracture care
  • Severe bone pain or deformity from known, or suspected metabolic bone disease
​Category 2
Recommended to be seen within 90 calendar days.

  • Aromatase inhibitor or androgen deprivation therapy
    not receiving anti-resorptive treatment and requiring specialist advice
  • Consideration for osteoanabolic therapy (as first-line treatment) in a very high fracture risk patient
    Note: patients must be treatment-naive and meet one of the following criteria:
    (a) symptomatic minimal trauma hip or vertebral fracture in the past 2 years
    (b) 2 minimal trauma fractures with one symptomatic fracture in the past 2 years
    (c) FRAX 10-year risk score major osteoporotic fracture (MOF) risk > 30% or hip fracture risk > 4.5%
  • Long-term glucocorticoid use (> 3 months anticipated duration) glucocorticoids (prednisone dosage > 7.5 mg/day, or equivalent as per PBS criteria) with bone mineral density (BMD) T-score < -1.5 requiring therapy with intolerance or contraindication to anti-resorptive therapy
  • Medication-related osteonecrosis of the jaw
    Note: surgical denial or maxillary issues will still require referral to oral or maxillofacial surgeon or dentists
  • Metabolic bone disease, including, but not limited to:
    • Symptomatic Paget's disease
    • Symptomatic fibrous dysplasia
    • Osteomalacia
  • Patients requiring denosumab cessation or exit strategy, or escalation of therapy
    Note: include reason for planned cessation and date of last denosumab dose in referral
  • Recent minimal trauma fracture for which specialist input is required before osteoporosis treatment can be commenced
  • Young people transitioning from paediatric to adult care 

Category 3
Recommended to be seen within 365 calendar days.

  • Post-menopausal women and men aged > 50 years with BMD T-score ≤ -2.5 and no history of minimal trauma fracture) requiring specialist advice for any of the following features:
    • Intolerance of, or contraindication to standard therapy
    • Suspected treatment failure with declining BMD despite therapy with adequate patient medication adherence
  • Complex treatment considerations in osteoporosis requiring specialist advice, including, but not limited to:
    • Aged < 30 years
    • Chronic kidney disease (eGFR < 30 mL/min/1.73m²)
    • Secondary causes (excluding glucocorticoid-induced osteoporosis)
  • Minimal trauma fracture in pre-menopausal women
  • Osteogenesis imperfecta
  • Recent minimal trauma fracture for which specialist input is required before osteoporosis treatment can be commenced

Information to include within a referral

Required

  • Reason for referral
  • Details of the presenting condition, including symptoms and their duration
  • Provisional diagnosis
  • Patient health summary (such as relevant medical history, relevant investigations,
    current medications and dosages, immunisations, allergies and/or adverse reactions), including specifically:
    • Minimal trauma fracture history (including parental hip fracture)
    • Bone mineral density (BMD) test results within past 12 month
      Note: BMD testing is not necessary, but highly recommended
    • Previous osteoporosis treatment, including date of treatment
    • Medication risk factors (especially aromatase inhibitor, androgen deprivation therapy, corticosteroids)
    • Test results (within past 3 months; fasting, early morning)
    • Urea, electrolytes, renal function
    • Calcium, magnesium, phosphate (CMP)
    • Vitamin D (25(OH)D)
    • Thyroid stimulating hormone (TSH)
    • Parathyroid hormone (PTH) (only if abnormal calcium or phosphate)

Note: consider using the Royal Australian College of General Practitioners (RACGP) and Healthy Bones Australia - Osteoporosis Risk Assessment, Diagnosis and Management flow chart

If available

  • Menopausal status (if known)
  • Risk factors (e.g. smoking, excess alcohol, poor balance, falls, low body weight)
    Note: consider using the Healthy Bones Australia – Osteoporosis Risk Assessment, Diagnosis and Management flow chart
  • X-ray: lateral thoracolumbar spine within 2 years
  • Test results (within past 3 months; fasting, early morning):
    • Liver function tests (LFTs)
    • Coeliac serology
    • Serum protein electrophoresis (SPEP)
    • Electrophoresis (EPG)
    • Immunofixation electrophoresis (IEPG)
    • Thyroid stimulating hormone (TSH)
    • Testosterone (males only)
    • Oestradiol, follicle-stimulating hormone (FSH),
    • Luteinising hormone (LH) (pre-menopausal women only)
    • Parathyroid hormone (PTH)
  • ​Current or previous radiological reports of any fractures
  • Date of final paediatric appointment, if attended and potential barriers to engagement 
    (e.g. move away from supports risk of homelessness) (if young person transitioning from paediatric to adult care)

Important information for referring health professionals

If there is a change to a patient’s condition while waiting for their appointment, referring health professionals may further investigate and manage the situation, or send an updated referral to the outpatient service. Where there are significant concerns about a patient's condition, referring health professionals may check HealthPathways for urgent/same day advice or contact the relevant clinical team. 

Current as at: Monday 23 March 2026
Contact page owner: System Purchasing