To help evaluate and monitor the rate of bone resorption and formation; to monitor some metabolic bone diseases such as osteoporosis; to help detect metabolic bone disorders such as Paget disease
Bone Markers
Bone Markers
Also Known As
Bone Resorption Markers
Bone Formation Markers
Bone Turnover Tests
N-telopeptide
NTx
C-telopeptide
CTx
Deoxypyridinoline
DPD
Pyridinium Crosslinks
Tartrate-resistant Acid Phosphatase
TRAP
Bone-specific Alkaline Phosphatase
Osteocalcin
P1NP
Procollagen Type 1 N-Terminal Propeptide
Formal Name
Biochemical Markers of Bone Remodeling
This article was last reviewed
on
This article waslast modified
on May 1, 2019.
At a Glance
Why Get Tested?
When To Get Tested?
When a bone mineral density scan indicates reduced bone density; before and periodically during treatment for bone loss to evaluate effectiveness, to determine if the rate of loss has decreased or the rate of bone formation has increased
Sample Required?
A blood sample drawn from a vein in your arm or sometimes a urine sample
Test Preparation Needed?
Fasting may be required before testing; samples are typically collected in the morning.
Accordion Title
Common Questions
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How is it used?
One or more of the bone marker tests may be used to help determine if a person has an increased rate of bone turnover (resorption and/or formation). Bone markers are sometimes used as an adjunct to bone density testing (e.g., BMD, DEXA scan) to help evaluate bone loss and detect some bone diseases.
In adults, bone markers often are used to monitor response to anti-resorptive therapy for bone disease, primarily osteoporosis, and to help determine if the dose of the drug a person is receiving is effective.
In children, these tests are primarily used to help detect and manage metabolic bone disorders, such as secondary osteoporosis, rickets, Paget disease, and osteogenesis imperfecta.
These tests can detect response to anti-resorption or bone formation therapies in a much shorter time period than the X-ray types of bone density testing (three to six months versus one to two years). This way, therapy can be adjusted or altered in a more timely manner if a person is not responding as expected.
The International Osteoporosis Foundation (IOF) and the International Federation for Clinical Chemistry (IFCC) recommend two blood tests for evaluating bone turnover:
- C-telopeptide (C-terminal telopeptide of type 1 collagen (CTx)) – a marker for bone resorption. It is a peptide fragment from the carboxy terminal end of the protein matrix; used to monitor anti-resorptive therapies, such as bisphosphonates and hormone replacement therapy, in postmenopausal women and people with low bone mass (osteopenia)
- P1NP (Procollagen type 1 N-terminal propeptide) – a marker for bone formation. It is formed by osteoblasts; reflects rate of collagen and bone formation; may be ordered along with bone resorption marker such as C or N-telopeptide; most sensitive marker of bone formation and particularly useful for monitoring bone formation therapies and anti-resorptive therapies; it is recommended that the test be performed at baseline before starting osteoporosis therapy and again 3 to 6 months later.
Other urine or blood tests used less commonly for bone resorption include:
- N-telopeptide (N-terminal telopeptide of type 1 collagen (NTx)) – a peptide fragment from the amino terminal end of the protein matrix; another marker used to monitor therapy.
- Deoxypyridinoline (DPD) – a collagen breakdown product with a ring structure.
- Pyridinium Crosslinks – a group of collagen breakdown products that includes DPD; used to monitor therapy response; not as specific for bone collagen as the telopeptides.
- Tartrate-resistant acid phosphatase (TRAP) is the version of acid phosphatase produced by osteoclasts, the cells that dissolve small amounts of bone, during bone resorption.
Other bone formation blood tests that may sometimes be used include:
- Bone-specific alkaline phosphatase (ALP) – one of the isoenzymes (types) of ALP; it is associated with osteoblast cell function, the type of cell involved in bone formation. It is thought to have a role in bone mineralization; it is recommended that the test be performed at baseline before starting osteoporosis therapy and again 3 to 6 months later; results may be affected by the level of liver ALP.
- Osteocalcin (bone gla protein) – a protein formed by osteoblasts; part of the non-collagen portion of the bone structure; some of it also enters the bloodstream; the level of osteocalcin in the blood reflects the rate of bone formation, thus it is a useful indicator of the function of osteoblasts. This test may be affected by use of the drug warfarin (Coumadin®).
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When is it ordered?
Testing may be performed along with other tests such as a calcium, vitamin D, thyroid testing, and parathyroid hormone when bone loss is detected during a bone mineral density test (diagnostic imaging) and/or when a person has a history of unexpected bone fracture.
In children, testing may be done when they have signs and symptoms suggesting a metabolic bone disorder, such as:
- Bone and/or joint pain
- Increased frequency of fractures
- Delayed growth and bone development
- Deformed bones
- Brittle teeth
For managing and treating bone diseases, one or more bone marker tests may be performed prior to anti-resorptive or bone formation therapy and then typically 3 to 6 months later to monitor the effectiveness of treatment.
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What does the test result mean?
A high level of one or more bone markers in urine and/or blood suggests an increased rate of resorption and/or formation of bone, but it does not indicate the cause (it is not diagnostic). An elevated level of bone markers may be seen in conditions such as:
- Osteoporosis
- Paget disease
- Cancer that has spread to the bone (metastatic bone disease)
- Hyperparathyroidism
- Hyperthyroidism
- Osteomalacia in adults and rickets in children—lack of bone mineralization, often due to vitamin D or calcium deficiency
- Chronic kidney disease (renal osteodystrophy)
- Excess use or high doses of glucocorticoids or Cushing syndrome
A low or normal level suggests no excessive bone turnover.
When used to monitor anti-resorptive therapy, decreasing levels of the bone resorption markers over time reflect a response to therapy.
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Is there anything else I should know?
Samples must be consistently collected, and test results must be interpreted with caution. There is both day-to-day variability in bone marker concentrations and diurnal variation (changes throughout the day). Most bone marker concentrations will be the highest in the morning, and some, in particular, alkaline phosphatase, are affected by eating.
Concentrations of bone markers are affected by a variety of factors, particularly during childhood development. These include age, sex, growth velocity, nutritional status, and puberty. Therefore, interpretation of bone marker values require use of appropriate reference intervals.
Most people with bone loss are not aware of it. The condition may not cause any symptoms until a person has an unexpected bone fracture.
Since people with breast or prostate cancer have a high incidence of bone metastases, there is also some evidence that bone markers can help healthcare practitioners predict which breast and prostate cancer patients may be at a high risk for complications from bone metastases and thus eligible for bone resorption sparing medications such as the bisphosphonates.
There are limitations to the clinical utility of many of these bone markers, but researchers continue to explore ways to improve their clinical use.
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Should everyone have bone marker testing performed?
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Will I have all or just some of these bone markers tested?
Typically, no one will have all of the tests done that are described here. Most healthcare practitioners use one or a few particular bone markers, including one or two that evaluate bone resorption and one or two that evaluate bone formation. The choice of bone markers will depend on many factors, including your medical history, signs and symptoms, and physical examination, and these all vary from person to person. Your healthcare practitioner will make the selection based on the usefulness of the tests for your condition. In general, if a test is ordered as a baseline prior to therapy, then the same test will be ordered later so that the two results can be compared.
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Can testing be performed in my healthcare practitioner's office?
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What can I do to increase or decrease bone marker results?