These baseline labs should be drawn on everyone with osteoporosis if not recently done. They serve to screen for common secondary etiologies (examples below) as well as ensure pharmacologic treatment is safe.

• CBC
  • If anemia, consideration of multiple myeloma
• Comprehensive metabolic panel
  • If elevated alkaline phosphatase, consider Paget’s disease.
  • If elevated calcium, correct for albumin and check a PTH in consideration of hyperparathyroidism
• Phosphorus
  • In CKD, may suggest mineral bone disease
• 25-hydroxy vitamin D
  • If low, supplement to goal of 30 ng/mL. Quick guide:
    • (30 – serum level) x 100 = # of international units daily
• TSH
  • Hyperthyroidism can contributes to bone loss
• 24-hour urinary calcium and creatinine
  • The presence of hypercalciuria can contribute to osteoporosis as it may represent a parathyroid disorder or malabsorption/low dietary intake, or a variety of other conditions.
  • See UCSF Heath for more info

Why order these tests? There is not consensus on the laboratory evaluation of osteoporosis. We based these recommendations on clinical experience and studies.

In a 2002 study in JCEM (Yield of Laboratory Testing to Identify Secondary Contributors to Osteoporosis in Otherwise Healthy Women) examining 173 women seen in an osteoporosis clinic in Mt. Sinai who had received extensive lab work up (as described above), about 1/3 women had a previously undiagnosed disorder. A testing strategy as recommended here would have picked up 85% of that group and is fairly cost effective.

• Abnormal baseline labs should prompt a secondary work up
  • For example, anemia and hyperproteinemia suggests multiple myeloma; a low vitamin D may suggest a malabsorption, etc.

• Perform a medication review and deprescribe if no longer indicated

• Additional labs (in addition to baseline labs:
  • PTH
  • +/- testosterone (men)

• Consider additional secondary evaluation based on clinical suspicion or endocrinology consultation

• At least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity

• Whole body strengthening activity at least twice per week

• Consider balance training, especially if fall risk

• Calcium: Women 50+ and Men 70+ = 1,200 mg daily; all else 1,000 mg daily
  • Calcium calculator
  • Dietary calcium estimation: Number of dairy servings x 300 mg + 300 mg in general diet (unless restrictive diet like vegan, keto, etc.)
    
• Vitamin D: All adults 50+: ~600-800 international units daily
  • Supplement to goal of 30+ ng/dL
  • Best evidence for supplementation is in older adults living in residential care, likely because they are often deficient

Refer to dentist before starting pharmacotherapy if retained root, ulceration, extraction needed based on physical exam

• “If a tooth extraction or implant is planned or ongoing initiation of potent antiresorptive therapy could be deferred until the area is healed.” JCEM 2019 – osteonecrosis of the jaw

PEARL: The risk of osteonecrosis of the jaw is rare (on bisphosphonates: about 1 in 10,000-100,000) but increases to 1 in 200 with extraction/invasive dental procedure) JCEM 2019

Good for everything, including bones!