RheumReferral

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Referring provider

Co-Management

Many patients do best with shared care. Here is what usually sits with primary care, what to monitor, and when to contact rheumatology.

Shared-care arrangements vary. Some rheumatology practices see these conditions routinely; follow your local agreement and the prescribing team's plan.

Adults

DMARD monitoring for stable rheumatic conditions

Most monitoring of stable patients on DMARDs can happen close to home under a shared-care plan, with rheumatology setting the drug, dose and target.

Primary care role

  • Order the scheduled blood tests and review the trend, not just the latest value (see the DMARD monitoring table).
  • Pause methotrexate and other DMARDs during a severe infection (for example, one needing IV antibiotics or hospital admission), and let rheumatology know. Restart when the infection has settled.
  • Keep vaccines up to date: inactivated vaccines are safe on DMARDs. Avoid live vaccines on most immunosuppressants unless rheumatology agrees.
  • Check for interactions when prescribing. Avoid trimethoprim or trimethoprim-sulfamethoxazole with methotrexate, and febuxostat with azathioprine (contraindicated), or allopurinol with azathioprine unless the specialist has adjusted the dose.
  • Reinforce sun protection and skin checks on azathioprine, and cardiovascular risk management for everyone.

Monitoring

  • Labs at the interval the shared-care plan sets: usually every 2–4 weeks at the start or after a dose increase, then about monthly, and about every 3 months once stable
  • Blood pressure and weight on leflunomide
  • A baseline retinal exam soon after starting hydroxychloroquine, then annual screening after 5 years of use (from the start with risk factors)

When to contact rheumatology

  • A clear downward trend in white cells, neutrophils or platelets, or a sustained rise in liver tests
  • Results crossing the action thresholds in the DMARD table
  • New cough or breathlessness on methotrexate (possible pneumonitis)
  • Pregnancy, or plans for it
  • A flare with new joint swelling
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Gout

Most gout can be treated well in primary care with a treat-to-target urate plan. Rheumatology helps when gout is tophaceous, refractory or complicated by CKD.

Primary care role

  • Treat flares early with colchicine, an NSAID or a glucocorticoid (oral or intra-articular).
  • Start allopurinol at 100 mg daily or less (lower in CKD 3 or worse) and increase every few weeks (often every 2–5 weeks) to a serum urate below 6 mg/dL.
  • Give flare prophylaxis (usually low-dose colchicine) for 3–6 months when starting ULT.
  • Consider HLA-B*58:01 testing before allopurinol in patients of Southeast Asian descent and in African American patients.
  • Review diuretics, alcohol and sugar-sweetened drinks; treat cardiovascular risk.

Monitoring

  • Serum urate after each dose increase (often every 2–5 weeks), then about every 6 months
  • eGFR and liver tests during dose titration

When to contact rheumatology

  • Tophi, or flares continuing despite urate at target
  • Urate not at target despite titration, or allopurinol intolerance or hypersensitivity
  • CKD 4–5 or transplant
  • Diagnostic doubt (gout vs CPPD vs infection)
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Osteoarthritis

OA is diagnosed clinically and treated mainly with exercise, weight management and simple analgesia.

Primary care role

  • Exercise and weight loss for knee and hip OA (strong recommendations). For knee OA with obesity, the 2026 ACR update conditionally recommends a GLP-1 receptor agonist with diet and exercise.
  • Topical NSAIDs for knee and hand OA, oral NSAIDs where safe, intra-articular glucocorticoids, duloxetine.
  • PT and OT referral, braces, hand orthoses, canes.
  • Avoid glucosamine or chondroitin, PRP, stem cell injections and hydroxychloroquine (strong recommendations against). Opioids and hyaluronic acid injections are conditionally not recommended.

Monitoring

  • Function and pain over time; imaging only if the clinical picture changes

When to contact rheumatology

  • Joint swelling with inflammatory features
  • An atypical pattern (MCP, wrist, shoulder), young onset or rapid progression
  • Erosive hand OA, where methotrexate is now a conditional option
  • Orthopedic referral for severe symptoms despite core treatment
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Osteoporosis

Includes glucocorticoid-induced osteoporosis. Most osteoporosis is treated in primary care, with specialist input for complex cases.

Primary care role

  • Screen women 65 and older, and younger postmenopausal women at increased risk (USPSTF 2025).
  • Assess fracture risk in anyone on prednisone 2.5 mg daily or more for 3 months or more (ACR 2022 GIOP), with calcium, vitamin D and lifestyle advice.
  • Outside glucocorticoid-induced osteoporosis, a bisphosphonate is first-line for most patients at moderate to high risk. In glucocorticoid-induced osteoporosis (ACR 2022), a bisphosphonate, denosumab or PTH/PTHrP analog are all options at moderate risk; at high risk denosumab or PTH/PTHrP analogs are conditionally preferred over a bisphosphonate; at very high risk a PTH/PTHrP analog is preferred.
  • Never stop denosumab without a plan. Follow it with a bisphosphonate to prevent rebound vertebral fractures.
  • In advanced CKD or on dialysis, decide on denosumab with nephrology, correct low calcium first, and check calcium closely 2–10 weeks after each dose (FDA boxed warning, 2024).

Monitoring

  • DXA every 1–3 years depending on risk and treatment; on long-term glucocorticoids, every 1–2 years with vertebral fracture assessment or spine X-ray (ACR 2022)
  • Calcium, vitamin D and kidney function as indicated
  • Reassess after 3–5 years of bisphosphonate (drug holiday decisions)

When to contact rheumatology

  • A fragility fracture while on treatment
  • Very high risk where anabolic therapy (teriparatide, abaloparatide, romosozumab) may be needed
  • Atypical femoral fracture, osteonecrosis of the jaw, or intolerance of standard options
  • Secondary causes that need investigation, or young patients
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Polymyalgia rheumatica: shared care

PMR without GCA features can often be managed in primary care, with rheumatology advice when needed. If you're not comfortable with the diagnosis or treatment, refer: it's better for the patient to be seen sooner rather than later. Guidelines differ: EULAR 2025 recommends specialist assessment of all suspected PMR, while BSR 2026 expects most PMR to be managed in primary care.

Primary care role

  • Ask about GCA symptoms at every visit: headache, jaw claudication, visual change, limb claudication. Any of these needs a same-day call.
  • Complete the workup before glucocorticoids start (ESR, CRP, CBC, metabolic panel, CK, TSH, RF/anti-CCP, protein electrophoresis); a 'trial of steroids' shouldn't be used as a diagnostic test.
  • Taper steadily. A typical plan starts prednisone at 15–25 mg daily, reaches 10 mg daily within about 2 months, then reduces slowly, aiming to stop within about a year.
  • Bone protection, blood pressure, glucose and weight checks during treatment.

Monitoring

  • Symptoms and ESR/CRP at each taper step
  • Glucose, blood pressure and bone health on glucocorticoids

When to contact rheumatology

  • Relapse on taper, or the dose can't be reduced below about 5–7.5 mg
  • Atypical features, or a poor response to glucocorticoids (reconsider the diagnosis)
  • Glucocorticoid side effects where a steroid-sparing drug (sarilumab, tocilizumab, methotrexate) may help
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Fibromyalgia

A clear diagnosis and an active, non-drug plan help most. Fibromyalgia also often coexists with inflammatory disease.

Primary care role

  • Make and explain the diagnosis; a focused workup is enough (CBC, metabolic panel, ESR/CRP, TSH).
  • Graded aerobic exercise first, then sleep, mood and CBT-based approaches.
  • Medicines with evidence: duloxetine, milnacipran, pregabalin, low-dose amitriptyline, and sublingual cyclobenzaprine (FDA-approved in 2025). Avoid opioids.

Monitoring

  • Function, sleep and mood rather than pain scores alone

When to contact rheumatology

  • Objective synovitis, raised inflammatory markers or other signs of inflammatory disease
  • Real diagnostic uncertainty
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Primary Raynaud's phenomenon

Symmetric attacks starting in youth, with no tissue injury and a negative or low-titer ANA.

Primary care role

  • Keep the whole body warm, stop smoking, avoid vasoconstricting drugs where possible.
  • A dihydropyridine calcium channel blocker for frequent or severe attacks.

Monitoring

  • New features at follow-up: ulcers, pitting, puffy fingers, skin tightening, reflux, breathlessness

When to contact rheumatology

  • Digital ulcers or pitting (urgent), or critical ischemia (emergent)
  • A newly positive specific antibody, abnormal capillaries, onset after about 30–40, or asymmetry
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Sjögren's disease: sicca-predominant

Dryness without systemic features is often looked after in primary care, with dental and eye care, and periodic specialist review.

Primary care role

  • Artificial tears, saliva substitutes, sugar-free lozenges, humidifiers; review drying medicines.
  • Regular dental care with fluoride; treat oral candidiasis.
  • Pilocarpine or cevimeline for glandular dryness if tolerated.
  • Counsel SSA/Ro-positive women about pregnancy planning (neonatal lupus risk).

Monitoring

  • CBC, urinalysis and immunoglobulins periodically; a check for gland swelling and lymph nodes

When to contact rheumatology

  • Persistent parotid swelling, new lymphadenopathy, purpura, cytopenias, low C4 or a monoclonal protein (lymphoma risk)
  • Neuropathy, kidney or lung involvement
  • Pregnancy planning in SSA/Ro-positive women
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Lupus between rheumatology visits

Primary care often sees early signs of a lupus flare first. A few simple checks catch kidney involvement early.

Primary care role

  • Blood pressure and urinalysis at visits; ask about rash, ulcers, joint swelling, chest pain and fevers.
  • Encourage hydroxychloroquine adherence; it lowers flare risk and is recommended for nearly everyone with SLE.
  • Cardiovascular risk management, sun protection, vaccines (inactivated), smoking cessation.
  • Contraception and pregnancy planning advice; estrogen-containing contraception is generally avoided with antiphospholipid antibodies.

Monitoring

  • CBC, metabolic panel, urinalysis with protein-to-creatinine ratio, C3/C4 and anti-dsDNA at the interval rheumatology sets
  • Retinal screening on hydroxychloroquine

When to contact rheumatology

  • New proteinuria, hematuria or a rising creatinine (call promptly)
  • New cytopenias, chest pain, neurologic symptoms, or a flare
  • Pregnancy, or plans for it
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Rheumatoid arthritis: whole-person care

People with RA have higher cardiovascular, infection, osteoporosis and lung disease risk. Much of this care sits naturally in primary care.

Primary care role

  • Cardiovascular risk assessment and management. EULAR suggests multiplying risk-calculator results by about 1.5 in RA if the tool doesn't include RA.
  • Vaccines, including recombinant zoster vaccine and pneumococcal vaccines.
  • Bone health (FRAX, DXA) and fall risk.
  • Ask about cough or breathlessness (RA-associated ILD), and support smoking cessation.
  • Age-appropriate cancer screening, including skin checks on some therapies.

Monitoring

  • DMARD labs per the shared-care plan
  • Function and joint swelling at visits

When to contact rheumatology

  • New swollen joints or a flare
  • New cough or breathlessness
  • Infection on biologic or targeted therapy
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Axial spondyloarthritis: shared care

Exercise is central to axSpA care, and primary care helps with the conditions that travel with it.

Primary care role

  • Encourage a regular exercise program and physical therapy (strongly recommended).
  • Teach the symptoms of uveitis (painful red eye, light sensitivity), which needs same-day eye care.
  • Ask about bowel symptoms (IBD) and psoriasis; manage cardiovascular risk, bone health and mood.
  • People with spinal fusion or kyphosis: fracture can follow minor trauma, so image the spine after a fall even with mild pain.

Monitoring

  • Symptoms and function; CRP as agreed with rheumatology

When to contact rheumatology

  • Uveitis episodes, new peripheral arthritis or enthesitis, or poor control on current treatment
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Vaccines on immunosuppression

Most vaccines can be given during treatment. Timing around a few drugs matters.

Primary care role

  • Inactivated vaccines (influenza, COVID-19, pneumococcal, recombinant zoster, hepatitis B, HPV, Tdap) are safe on DMARDs and biologics.
  • Recombinant zoster vaccine is recommended from age 18 for people on immunosuppressive treatment.
  • High-dose or adjuvanted influenza vaccine is preferred for older adults and conditionally for younger adults on immunosuppression (ACR 2022).
  • Methotrexate: consider holding it for 2 weeks after influenza vaccination if disease activity allows (ACR 2022).
  • Rituximab blunts responses for about 6 months. Give inactivated vaccines at least 2 weeks before a cycle where possible.
  • Live vaccines are generally avoided on immunosuppression. Plan them before treatment starts where possible, and agree timing with rheumatology.

Monitoring

  • Vaccine record reviewed at least yearly

When to contact rheumatology

  • Any live vaccine decision, or travel vaccines, for a patient on immunosuppression
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Surgery and procedures

For elective hip and knee replacement, the ACR/AAHKS 2022 guideline gives practical holding rules.

Primary care role

  • Continue methotrexate, leflunomide, hydroxychloroquine and sulfasalazine through surgery.
  • Hold biologics so surgery falls at the end of the dosing interval, and restart about 14 days after surgery once the wound is healing and there is no infection.
  • Hold JAK inhibitors for 3 days before surgery.
  • Continue the usual daily glucocorticoid dose rather than giving routine 'stress doses'.
  • Dental work rarely needs changes to rheumatology medicines.

Monitoring

  • Wound healing and infection signs before restarting biologics

When to contact rheumatology

  • Lupus, myositis or vasculitis on mycophenolate, azathioprine or calcineurin inhibitors (plans differ by disease severity)
  • Emergency surgery on biologics or JAK inhibitors
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Glucocorticoid safety

Long-term glucocorticoids need active management of their side effects, whoever prescribes them.

Primary care role

  • Bone protection from the start if 2.5 mg prednisone or more is expected for 3 months or more.
  • Check blood pressure, glucose, weight and mood; eye checks for cataract and glaucoma.
  • Consider Pneumocystis prophylaxis when doses of about 20 mg or more are used for 4 weeks or longer together with another immunosuppressant (follow rheumatology advice).
  • Taper rather than stop suddenly after more than about 3 weeks; consider adrenal insufficiency with symptoms during a taper.

Monitoring

  • Glucose, blood pressure and weight at visits; DXA and FRAX per GIOP guidance

When to contact rheumatology

  • Inability to taper, or significant side effects (a steroid-sparing drug may be needed)
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Sarcoidosis

Usually shared with pulmonology. Many patients need monitoring rather than treatment.

Primary care role

  • Coordinate with pulmonology for lung disease; eye examination at diagnosis.
  • Löfgren syndrome often settles with NSAIDs and time.

Monitoring

  • Calcium, kidney and liver tests, ECG; PFTs and imaging as advised

When to contact rheumatology

  • Chronic arthritis, skin disease such as lupus pernio, uveitis, or suspected cardiac or neurologic involvement
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Drug-induced rheumatic conditions

Stopping or switching the culprit is often the most important step.

Primary care role

  • Recognize drug-induced lupus (hydralazine, procainamide, minocycline, isoniazid, TNF inhibitors), statin myopathy, aromatase inhibitor arthralgia and fluoroquinolone tendinopathy.
  • Stop or switch the medicine where possible, with the prescriber.

Monitoring

  • Symptoms over weeks to months after withdrawal; CK trend for statin myopathy

When to contact rheumatology

  • Symptoms lasting more than about a month after withdrawal, organ involvement, or uncertainty
  • Checkpoint inhibitor rheumatic adverse events, which need prompt shared care with oncology
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Children and adolescents

JIA: between pediatric rheumatology visits

Pediatricians and family physicians keep children with JIA growing, vaccinated and screened.

Primary care role

  • Track growth and pubertal development; active inflammation and glucocorticoids affect growth.
  • Make sure uveitis screening happens on schedule (every 3 months for high-risk children).
  • Keep inactivated vaccines up to date; live vaccines need discussion on DMARDs or biologics.
  • Encourage physical activity, school participation and mental health support.

Monitoring

  • Methotrexate: CBC, liver tests and kidney function within the first 1–2 months, then every 3–4 months (ACR 2026)
  • TNF inhibitors: CBC and liver tests yearly; IL-6 inhibitors: within 1–2 months, then every 3–4 months, plus lipids every 6 months
  • NSAIDs: CBC, liver tests and kidney function every 6–12 months

When to contact rheumatology

  • New joint swelling or a flare
  • Uveitis found on screening
  • Slowing growth, abnormal labs or side effects
  • Transition planning
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PFAPA

The most common periodic fever in young children. Episodes are stereotyped, and the child is well between them.

Primary care role

  • Keep a fever diary; confirm well intervals and normal growth.
  • A single dose of prednisone at fever onset usually aborts an episode (episodes may come more often afterward).
  • Tonsillectomy can be curative for some children; discuss with ENT.

Monitoring

  • Episode frequency and response to treatment

When to contact rheumatology

  • Atypical features (onset after 5, rash, arthritis, abdominal pain, poor growth), no response to prednisone, or a family history suggesting a monogenic fever
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Childhood lupus: between visits

Childhood-onset lupus is often more severe than adult lupus, with more kidney disease.

Primary care role

  • Blood pressure and urinalysis at every visit.
  • Hydroxychloroquine adherence, sun protection, inactivated vaccines, bone health and mood.

Monitoring

  • CBC, metabolic panel, urinalysis, C3/C4 at the interval rheumatology sets; lipids yearly

When to contact rheumatology

  • New proteinuria, hematuria or rising creatinine
  • New cytopenias or symptoms
  • Transition planning
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IgA vasculitis (HSP): after the acute episode

Kidney involvement can appear weeks to months after the rash.

Primary care role

  • Urinalysis and blood pressure regularly for at least 6–12 months (SHARE 2019), more often in the first weeks.
  • Supportive care for pain; watch for severe abdominal pain (intussusception).

Monitoring

  • Urinalysis (blood, protein), urine protein-to-creatinine ratio if protein is present, blood pressure, creatinine if abnormal

When to contact rheumatology

  • Persistent or heavy proteinuria, nephritic or nephrotic features, a rising creatinine, hypertension, or recurrent episodes (pediatric nephrology or rheumatology)
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Kawasaki disease: after discharge

Follow-up is led by cardiology, but primary care manages vaccines and aspirin safety.

Primary care role

  • Delay measles- and varicella-containing vaccines for 11 months after high-dose IVIG.
  • Give influenza vaccine (inactivated) to children on aspirin, and avoid live attenuated influenza vaccine; aspirin with influenza or varicella raises the risk of Reye syndrome.
  • Make sure follow-up echocardiograms happen as scheduled.

Monitoring

  • Echocardiogram schedule per cardiology

When to contact rheumatology

  • Recurrent fever or new symptoms in the weeks after discharge
  • Coronary artery abnormalities (long-term cardiology care)
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Moving from pediatric to adult rheumatology

Many young people are lost to follow-up during transfer, and flares and organ damage can follow.

Primary care role

  • Start transition conversations around age 12–14; build self-management skills (medicines, appointments, refills).
  • Help identify an adult rheumatologist and make sure records and a medical summary move with the patient.
  • Stay involved; continuity in primary care is protective during the move.

Monitoring

  • Readiness for self-management at adolescent visits

When to contact rheumatology

  • A planned transfer with a warm handoff, rather than a sudden one
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