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Osteoporosis is a skeletal disorder characterized by decreased bone strength and density that leads to an increased risk of fracture. The disorder is common and may be asymptomatic and therefore remain undiagnosed until fractures occur. Screening recommendations for osteoporosis continue to evolve. Bone mineral density testing using imaging, such as dual-energy x-ray absorptiometry (DXA), is the gold standard approach for screening and diagnosis. Laboratory testing plays a supportive role and is used in the evaluation of secondary osteoporosis and the assessment of bone turnover.
Quick Answers for Clinicians
Laboratory testing plays a supporting role in the evaluation and monitoring of osteoporosis. Although the diagnosis of osteoporosis relies on clinical and imaging factors, secondary osteoporosis can be evaluated and diagnosed using laboratory tests. Laboratory testing may also be useful in risk assessment and monitoring.
No. The applicability of bone turnover markers to predict bone loss or risk of fracture is not established in all populations. 1 Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474.
Indications for Testing
A clinical evaluation for osteoporosis—including a history, physical exam, appropriate imaging if certain clinical features are present, and a fracture risk assessment tool when available—is recommended in postmenopausal women ≥50 years of age. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531. U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531.
Laboratory Testing
Testing for Causes of Secondary Osteoporosis
Many conditions are associated with bone loss and secondary osteoporosis. Laboratory testing should be considered to look for underlying causes in all individuals diagnosed with osteoporosis. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
Population | Recommended Laboratory Testing |
---|---|
All individuals with osteoporosis | 25(OH)D CBC Liver function tests Parathyroid hormone Serum metabolic panel:
|
Individuals with normal vitamin D concentrations and calcium intake (either initially or achieved via supplementation) | 24-hour urine with:
|
Individuals with suspected hyperthyroidism Individuals taking thyroid hormone | Serum TSH |
Men with osteoporosis | Total testosterone |
Individuals with suggestive clinical features | Homocysteine Prolactin Serum ferritin Serum iron Serum protein electrophoresis Tissue transglutaminase antibodies Tryptase Urine histamine Urine protein electrophoresis Urine or salivary free cortisol |
25(OH)D, 25-hydroxyvitamin D; eGFR, estimated glomerular filtration rate; TSH, thyroid-stimulating hormone Sources: Sources: Camacho, 2020 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. |
Testing for the following conditions, among others, may also be considered depending on the results of the clinical evaluation and initial tests 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822.
- Adrenal hyperfunction
- Celiac disease
- Chronic kidney disease
- Chronic obstructive pulmonary disease
- Hyperparathyroidism
- Hyperthyroidism
- Hypogonadism
- Mastocytosis
- Myeloma
- Osteomalacia
Genetic testing may be appropriate in individuals with features suggestive of a metabolic bone disorder. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
Bone Turnover Markers
Bone turnover marker testing may be useful to predict bone loss, assess fracture risk, provide a reference for analytes in clinical studies, and investigate the effects of therapy. 1 Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102.
Bone turnover marker tests may be costly, and reference ranges may not be well established. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
Bone Resorption Markers | |
---|---|
Marker | Use |
Serum CTX | Preferred marker of bone resorption Use to monitor antiresorptive treatments Reference analyte for bone turnover in clinical studies |
Serum or urine NTX | Alternative marker of bone resorption Use to monitor antiresorptive treatments |
Urine deoxypyridinoline | Alternative marker |
Bone Formation Markers | |
Marker | Use |
Serum PINP | Preferred marker of bone formation Use to monitor anabolic treatment Reference analyte for bone turnover in clinical studies |
Bone-specific alkaline phosphatase | Preferred marker if renal insufficiency is present Use to monitor anabolic treatment |
Osteocalcin | Alternative marker |
CTX, C-terminal telopeptide of type-1 collagen; NTX, N-telopeptide of type I collagen Sources: Greenblatt, 2017 1 Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. |
Monitoring
Bone Turnover Markers for Monitoring
Although osteoporosis is generally monitored using imaging to assess bone mineral density, this testing is not recommended during the initial years of therapy. 1 Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.
Although there is not a specific standard for optimal bone turnover marker concentrations, and although concentrations may vary depending on the specific treatment, an early decrease (in the first 1-6 months) in bone resorption markers or an increase in bone formation markers suggests good therapeutic response and that fracture risk may be reduced. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.
Other Monitoring Tests
Laboratory testing may be useful to assess for secondary osteoporosis in individuals with significant decreases in bone mineral density despite treatment. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
25(OH)D testing may be considered to evaluate for adequate vitamin D concentrations following supplementation in individuals with osteoporosis. 2 Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102.
ARUP Laboratory Tests
Quantitative Electrochemiluminescent Immunoassay
Quantitative Radioimmunoassay
Quantitative Immunoassay
Quantitative Chemiluminescent Immunoassay (CLIA)
Quantitative Enzyme-Linked Immunosorbent Assay
Quantitative Electrochemiluminescent Immunoassay
Quantitative Enzyme Immunoassay
References
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Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464-474.
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Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
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LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2022]. Osteoporos Int. 2022;33(10):2049-2102.
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U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531.
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Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822.
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Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.