Common Questions
What is an appropriate diagnostic work-up for secondary osteoporosis?
There are no evidence-based guidelines on how to evaluate patients for secondary causes of osteoporosis. The history and physical examination may suggest possible causes and should direct the work-up. Guidelines based on expert opinion have been developed by the National Osteoporosis Society, the American College of Rheumatology, and the American Association of Clinical Endocrinologists to help direct an appropriate work-up (1-4).
In patients with a fragility fracture at a young age, a z-score less than -2.0, or men with early fragility fractures or other evidence of osteoporosis, the following labs are recommended:
- CBC
- ESR
- Liver function studies including alkaline phosphatase and albumin
- Calcium, phosphate and creatinine
- TSH
If preliminary lab results or the history and physical indicate further work-up is necessary, the following may also help to identify secondary causes of osteoporosis.
- SPEP and UPEP
- Bone scan
- FSH if hormonal status is unclear in women
- Testosterone, LH and sex-hormone binding globulin
- 25-OH vitamin D and PTH
- 24-hour urine calcium
- Ferritin and iron studies
- 24-hour urine cortisol
| Abnormal Study | Suggested Pathology | |
|---|---|---|
 |
Calcium | Primary hyperparathyroidism or malignancy |
 |
Calcium | Malabsorption, osteomalacia |
|
Phosphorus | Osteomalacia |
|
Alkaline phosphatase | Paget's disease, fracture, osteomalacia,other bone pathology, liver disease |
|
Albumin | Malnutrition |
|
25-OH vitamin D | Osteomalacia |
|
Thyroid-stimulating hormone | Hyperthyroidism |
|
Creatinine | Renal disease |
|
Hepatic transaminases | Liver disease |
| Anemia | Hematologic disorder (i.e. multiple myeloma) | |
|
ESR | Malignancy, rheumatologic disease |
| SPEP/UPEP | Multiple myeloma | |
|
LH/FSH | Primary hypogonadism |
|
Estradiol/testosterone | Hypogonadism |
|
24-hour calcium excretion | Malabsorption, vitamin D deficiency |
|
24-hour urinary-free cortisol | Cushing's disease |
|
Iron studies | Hemochromatosis |
| POS | Bone scan | Metastases |
- National Osteoporosis Society. Guidelines on glucocorticoid-induced osteoporosis. 2002. Available online.
- American College of Rheumatology. Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis and Rheumatism 2001; 44;7: 1496-1503.
- Yeap SS, Hosking DJ. Management of corticosteroid-induced osteoporosis.. Rheumatology 2002; 41: 1088-1094.
- Hodgson SF, Watts NB, Bilezikian JP, Clarke BL, Gray TK, Harris DW, Johnston CC, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract 2003; 9;6: 544-564.