Bone turnover markers (BTMs) are released during the bone remodelling cycle and are measurable in blood or urine, reflecting bone remodelling rate. They have been useful in elucidating the pharmacodynamics and effectiveness of osteoporosis medication in clinical trials and are increasingly used in routine clinical management of osteoporosis, especially for monitoring therapy, in addition to their use in other metabolic bone disease such as Paget's disease of bone and osteomalacia. Serum β isomerised C-terminal telopeptide of type I collagen and pro-collagen I N-terminal propeptide have been designated as reference BTMs for use in osteoporosis. In addition, bone-specific isoenzyme of alkaline phosphatase (B-ALP) secreted by osteoblasts and tartrate-resistant acid phosphatase 5b (TRACP-5b) secreted by osteoclasts are also found to be specific markers of bone formation and resorption, respectively. The concentrations of the latter enzymes in blood measured by immunoassay provide reliable measures of bone turnover even in the presence of renal failure. B-ALP is recommended for use in the assessment of renal bone disease of chronic kidney disease, and TRACP-5b shows promise as a marker of bone resorption in that condition. BTMs in blood do not suffer from biological variation to the same extent as the older BTMs that were measured in urine. Appropriate patient preparation and sample handling are important in obtaining accurate measures of BTMs for clinical use. Reference change values and treatment targets have been determined for the reference BTMs for their use in monitoring osteoporosis treatment. Further ongoing studies will enhance their clinical applications.

Department of Clinical Biochemistry and Bone Metabolism Klatovska Hospital Klatovy Czech Republic

Department of Clinical Biochemistry and Haematology Faculty of Medicine Pilsen Charles University Prague Pilsen Czech Republic

Department of Clinical Chemistry University of Liège CHU de Liège Domaine du Sart Tilman 4000 Liège Belgium

Department of Laboratory Medicine Faculty of Medicine University of Debrecen Debrecen Hungary

Faculty of Health Care Studies University of West Bohemia Pilsen Czech Republic

Faculty of Pharmaceutical Sciences Hokuriku University Hokuriku University Healthy Aging Research Group 3 Ho Kanagawa machi Kanazawa City Ishikawa 9201181 Japan

PathWest Laboratory Medicine Fiona Stanley Hospital Murdoch WA Australia

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