Osteoporosis is a skeletal disorder characterized by decreased bone strength and density. Dual-energy x-ray absorptiometry (DXA) is the gold standard test for diagnosis. Laboratory testing is useful in ruling out secondary causes of osteoporosis. Bone turnover marker testing is available but is not the primary method for diagnosing or monitoring osteoporosis.
Diagnosis
Indications for Testing
Bone mineral density (BMD) testing (DXA) is recommended for women ≥65 years, postmenopausal women with risk factors, and men ≥70 years or younger men with risk factors (see Screening for details).
Laboratory Testing
- Testing for causes of secondary osteoporosis should be considered
- Serum calcium, phosphorus, magnesium
- If hypercalcemia present: evaluate for hyperparathyroidism, multiple myeloma, cancer
- Hypophosphatemia: suggests osteomalacia
- CBC: if anemia present, evaluate for underlying conditions, such as multiple myeloma, cancer, malabsorption
- Renal function testing: for renal disease assessment
- Alkaline phosphatase: evaluate for Paget disease
- 24-hour urine calcium: to detect hypercalciuria
- Serum albumin: malnutrition, malabsorption assessment
- Vitamin D 25(OH)D: for vitamin D deficiency; evaluate patients >50 years for malnutrition, malabsorption, and celiac disease
- Thyroid stimulating hormone (TSH): evaluate for hyperthyroidism
- Liver function tests: evaluate for chronic liver disease
- Testosterone (males): evaluate younger men for hypogonadism
- Parathyroid hormone (PTH) (intact or PTH-related protein [PTHrP]): evaluate for hyperparathyroidism
- Serum calcium, phosphorus, magnesium
- Testing for bone turnover
- Consider testing at initial diagnosis and at follow-up (Camacho, AACE, 2016; Cosman, National Osteoporosis Foundation [NOF], 2014)
- Higher rates of bone turnover are associated with higher fracture risk
Bone Formation Markers | Comments |
---|---|
Serum procollagen type 1 N-terminal propeptide
Serum procollagen type 1 C-terminal propeptide |
Most frequently used marker of bone formation
Expect reduced levels when on antiresorptive therapy |
Serum osteocalcin | Limited use in clinical practice due to variability |
Serum bone-specific alkaline phosphatase | Expect increased levels with antiresorptive therapies |
Bone Resorption Markers | |
Serum collagen type I cross-linked telopeptide | Most frequently used resorptive marker |
Urine or serum N-telopeptide | Fasting AM urine spot is optimal |
Urine pyridinoline | Expect reduced levels with antiresorptive therapies
Early AM spot urine sample is preferred |
Urine deoxypyridinoline | Expect reduced levels with antiresorptive therapies
Early AM spot urine sample is preferred |
Urine hydroxyproline | Nonspecific marker; also reflects bone formation |
HPLC, high-performance liquid chromatography |
Imaging Studies
Screening
Women | Women (postmenopausal) | Men | |
---|---|---|---|
USPSTF, 2018 | Women ≥65 years | Postmenopausal women <65 years considered at risk for osteoporosis based on formal risk assessment tool | Men: evidence is insufficient for a recommendation for or against screening in men |
NOF, 2014 | Women >65 years | Postmenopausal women >50 years with either risk factors or fracture (new or historical adult age fracture) | Men >70 years, or >50 years with risk factors or fracture (new or historical adult age fracture) |
ACR, 2017 | Women or men on glucocorticoids for 6 months, who are <40 years with risk factors or osteoporotic fracture, or ≥40 years | ||
ACR, American College of Rheumatology; USPSTF, U.S. Preventive Services Task Force
Sources: Cosman, NOF, 2014; Buckley, ACR, 2017; USPSTF, 2018 |
Monitoring
- Laboratory testing
- Bone turnover markers may be useful for monitoring therapy response (Camacho, AACE, 2016; Cosman, NOF, 2014)
- Vitamin D 25(OH)D: consider reevaluating for adequate concentrations after supplementation
- Imaging studies
- DXA: for monitoring during treatment
- Reevaluate at 1-2 years until stable, then repeat every 1-2 years, or less frequently if clinically indicated (Cosman, NOF, 2014)
ARUP Laboratory Tests
Quantitative Electrochemiluminescent Immunoassay
Quantitative Radioimmunoassay
Quantitative Immunoassay
Quantitative Chemiluminescent Immunoassay
Quantitative Enzyme-Linked Immunosorbent Assay
Quantitative Electrochemiluminescent Immunoassay
Quantitative Enzyme Immunoassay
Quantitative Chemiluminescent Immunoassay
High Performance Liquid Chromatography (HPLC)
Quantitative Spectrophotometry
Quantitative Spectrophotometry
Quantitative Spectrophotometry
Quantitative Spectrophotometry
Quantitative Chemiluminescent Immunoassay/Quantitative Enzyme-Linked Immunosorbent Assay
Panel includes albumin, calcium, carbon dioxide, creatinine, chloride, glucose, phosphorous, potassium, sodium, and blood urea nitrogen (BUN)
Quantitative Chemiluminescent Immunoassay
Quantitative Enzymatic Assay
Quantitative Spectrophotometry
Quantitative Chemiluminescent Immunoassay
Quantitative Electrochemiluminescent Immunoassay
Reflex: if TSH is outside the reference interval, then free thyroxine (T4) testing will be added
Quantitative Enzymatic Assay/Quantitative Spectrophotometry
Panel includes albumin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, bilirubin (direct and total), and protein (total)
Quantitative Electrochemiluminescent Immunoassay
References
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Buckley L, Guyatt G, Fink HA, et al. 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2017;69(8):1095-1110.
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Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016. Endocr Pract. 2016;22(Suppl 4):1-42.
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Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359-2381.
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Hans DB, Kanis JA, Baim S, et al. Joint official positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(Ž). Executive summary of the 2010 Position Development Conference on Interpretation and Use of FRAXŽ in Clinical Practice. J Clin Densitom. 2011;14(3):171-180.
ISCD - Osteoporosis
International Society for Clinical Densitometry. ISCD. Middletown, CT [Accessed: May 2018]
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McCloskey E, Johansson H, Oden A, et al. Fracture risk assessment. Clin Biochem. 2012;45(12):887-893.
Practice Bulletin 129: Osteoporosis-ACOG
Practice Bulletin 129: Osteoporosis (September 2012, Reaffirmed 2016) (Replaces Practice Bulletin Number 50, January 2004). Washington, DC: American College of Obstetricians and Gynecologists (ACOG). [Reaffirmed: 2016; Accessed: Jan 2018]
USPSTF - Final Recommendation Statement: Osteoporosis to Prevent Fractures: Screening
U.S. Preventive Services Task Force. Final recommendation statement: osteoporosis to prevent fractures: screening. Rockville, MD: [Published: Jun 2018; Accessed: Aug 2018]
Medical Experts
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