Copper (serum copper and ceruloplasmin)

Pick Ordered or Not ordered to see the note.

Indicated when

• —Suspected copper deficiency: malabsorption, prior bariatric or gastric surgery, total parenteral nutrition, or unexplained myeloneuropathy, anemia, or neutropenia, especially with a history of chronic or high-dose zinc supplementation [1]
• —Suspected Wilson disease: unexplained liver disease, especially in a young person, with or without neuropsychiatric features; ceruloplasmin is part of the initial work-up alongside 24-hour urine copper and a slit-lamp exam, never used alone [2]

Not indicated when

• —Routine or 'wellness panel' screening for fatigue or general immune support with no risk factor for copper deficiency and no Wilson-disease red flag [3]
• —Ruling out Wilson disease on a normal ceruloplasmin result alone, without the accompanying work-up

Why not

Ceruloplasmin has real interpretive limits in both directions. As an acute-phase reactant, it can rise with inflammation, masking a true underlying deficiency; and for the diagnosis it is most often ordered to rule out, a serum ceruloplasmin within the normal range does not exclude Wilson disease, so a reassuring result can still miss the diagnosis [2]. Copper deficiency itself is diagnosed by measuring serum copper, serum ceruloplasmin, and 24-hour urine copper together, not any single test in isolation [1].

Better first step

For suspected copper deficiency, order serum copper and ceruloplasmin together rather than either alone, since diagnosis is made by combining serum copper, serum ceruloplasmin, and 24-hour urine copper [1]. If Wilson disease is genuinely suspected, involve a specialist rather than relying on ceruloplasmin alone [2].

Typical ND rationale

An ND may order copper and ceruloplasmin, or check them before starting or continuing zinc supplementation, reasoning that copper and zinc absorption compete with each other and that copper deficiency from high-dose zinc use is easy to miss until it causes symptoms.

Ontario coverage & CONO orderability

OHIP status

insured

L063 Copper and L553 Ceruloplasmin are both listed in the 2026 Schedule of Benefits for Laboratory Services with no restricting condition, so both are insured when a physician orders them after clinically assessing the patient ([4]; [5]; Reg. 552 s.22). ND-ordered testing of either is patient-paid regardless [8].

CONO orderable

Yes — CONO list #44, #38

CONO list item 44, blood: 'Copper'; item 38, blood: 'Ceruloplasmin.'

Linked conditions

• tired ↗

Counselling script

“If you've had gut or weight-loss surgery, are on intravenous nutrition, or take high-dose zinc supplements regularly, checking copper makes sense, since it can genuinely run low in those situations. Without one of those, I wouldn't add it to routine bloodwork. If we're ever checking for the rare condition where copper builds up instead, that's never based on one test alone.”

Revisit if

• —Malabsorption, bariatric surgery, or starting total parenteral nutrition
• —Starting or continuing high-dose zinc supplementation
• —Unexplained myeloneuropathy, anemia, or neutropenia
• —Unexplained liver disease, especially in a young person

References

1. [1]Annals of Hematology (2018). Copper deficiency anemia: review article. linkCopper deficiency diagnosis is made by measuring serum copper, serum ceruloplasmin, and 24-hour urine copper together; causes include malabsorption, GI surgery, and excess zinc intake
2. [2]American Association for the Study of Liver Diseases (AASLD) (2022). A multidisciplinary approach to the diagnosis and management of Wilson disease: Executive summary of the 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. linkSerum ceruloplasmin is decreased in most Wilson disease patients but a normal-range result does not exclude the diagnosis; ceruloplasmin is used alongside other tests, not alone
3. [3]College of Family Physicians of Canada / Choosing Wisely Canada (2026). Family Medicine: Fifteen Tests and Treatments to Question. linkDon't do annual screening blood tests unless directly indicated by the patient's risk profile
4. [4]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026) - L063 Copper. linkL063 Copper is listed in the 2026 OHIP Schedule with no restricting condition
5. [5]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026) - L553 Ceruloplasmin. linkL553 Ceruloplasmin is listed in the 2026 OHIP Schedule with no restricting condition
6. [6]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkCommunity lab tests are insured only when ordered under the Schedule by an authorized prescriber
7. [7]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
8. [8]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services