Bone turnover: Biology and assessment tools

Best Pract Res Clin Endocrinol Metab. 2018 Oct;32(5):725-738. doi: 10.1016/j.beem.2018.05.003. Epub 2018 May 26.


Bone turnover includes two processes: resorption (removal of old bone) and formation (laying down of new bone). N-terminal propeptide of type I procollagen (PINP) and C-telopeptide of type I collagen (CTX-I) are markers of bone formation and resorption, respectively, that the International Osteoporosis Foundation and the International Federation of Clinical Chemistry recommend for clinical use. Bone turnover markers (BTM) are subject to sources of variability, including feeding (lower resorption) and recent fracture (increased levels of all markers). Controllable patient-related factors should be adapted as much as possible (eg blood collection after an overnight fast) to minimize pre-analytical variability. Uncontrollable factors should be considered in the interpretation of the BTM measurements. BTM do not improve prediction of bone loss or fracture within an individual. In osteoporotic patients, BTM may help to assess the response to anabolic and antiresorptive therapies, to assess compliance to the treatment, or to indicate possible secondary causes of osteoporosis. BTM reflect changes in bone metabolism induced by anti-osteoporotic treatment. Anti-resorptive drugs induce a rapid dose-dependent decrease in bone resorption, whereas bone formation stimulating medications increase the levels of bone formations markers. BTM may be used for monitoring anti-osteoporosis therapy. The expected effect during the anti-resorptive therapy is to decrease the PINP by at least 10 ng/mL and to attain the target level of less than 35 ng/mL. The expected effect during the bone formation-stimulating therapy is to increase the PINP by at least 10 ng/mL and to attain the target level of more than 69 ng/mL.

Keywords: C-terminal telopeptide of type I collagen; N-terminal extension propeptide of type I procollagen; anti-osteoporosis treatment; bone turnover markers; osteoporosis.

Publication types

  • Review

MeSH terms

  • Animals
  • Biomarkers / blood
  • Bone Density / physiology
  • Bone Diseases, Metabolic / diagnosis*
  • Bone Diseases, Metabolic / metabolism
  • Bone Diseases, Metabolic / pathology
  • Bone Remodeling / physiology*
  • Bone Resorption / blood
  • Bone Resorption / diagnosis
  • Bone Resorption / therapy
  • Bone and Bones / metabolism
  • Collagen Type I / blood
  • Fractures, Bone / diagnosis
  • Fractures, Bone / etiology
  • Fractures, Bone / therapy
  • Humans
  • Osteoporosis / diagnosis
  • Osteoporosis / drug therapy
  • Osteoporosis / etiology
  • Osteoporosis / therapy
  • Peptides / blood


  • Biomarkers
  • Collagen Type I
  • Peptides
  • collagen type I trimeric cross-linked peptide