What to do about elevated Alkaline Phosphatase (ALP) levels?

From the Guidelines

If you have elevated alkaline phosphatase (ALP) levels, you should first consult with your healthcare provider to determine the underlying cause, as treatment depends on what's driving the elevation. The most important step is diagnostic evaluation, which typically includes additional blood tests like gamma-glutamyl transferase (GGT), bilirubin, and liver function tests, as well as imaging studies such as ultrasound, CT scan, or MRI of the liver and biliary system. No specific medication directly lowers ALP; instead, treatment targets the underlying condition. For liver-related causes, addressing alcohol consumption, medication side effects, or viral hepatitis may be necessary. For bone-related elevations, vitamin D supplementation (typically 1,000-2,000 IU daily) and calcium (1,000-1,200 mg daily) might help if deficiency is present, as suggested by 1. If the elevation is due to biliary obstruction, procedures like endoscopic retrograde cholangiopancreatography (ERCP) may be required. While waiting for your appointment, avoid alcohol, review your medications with your doctor for potential liver effects, and maintain a healthy diet. ALP is an enzyme found primarily in the liver, bones, and bile ducts, so elevations can indicate problems in these areas, making proper diagnosis essential before starting any treatment. Some key points to consider include:

• Diagnostic evaluation is crucial to determine the underlying cause of elevated ALP levels.
• Treatment targets the underlying condition, not the ALP levels directly.
• Vitamin D and calcium supplementation may be beneficial for bone-related elevations.
• Procedures like ERCP may be necessary for biliary obstruction.
• Avoiding alcohol and maintaining a healthy diet is recommended while waiting for a diagnosis. According to 1, tissue is the source of the ALP elevation, and this can include gamma-glutamyl transferase (GGT) testing, which tends to be proportionately more elevated in cholestatic rather than hepatocellular liver injury. Additionally, fractionating alkaline phosphatase into its liver, bone, and intestinal isoenzyme fractions can also be very informative, as mentioned in 1. It's also important to note that liver tests should be obtained following treatment cessation and for a duration of at least five half-lives of the parent drug and major metabolites, or for a longer time period if the potential for delayed liver injury exists, such as with immune checkpoint inhibitors, as stated in 1. Overall, a comprehensive diagnostic evaluation and treatment plan are essential for managing elevated ALP levels, and this should be done under the guidance of a healthcare provider.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Causes of Elevated Alkaline Phosphatase (ALP) Levels

Elevated ALP levels can be caused by various factors, including:

• Underlying malignancy, such as infiltrative intrahepatic malignancy, bony metastasis, or both hepatic and bone metastasis 2
• Bone disease, such as Paget's disease or osteomalacia 2, 3
• Unsuspected parenchymal liver disease, such as liver cirrhosis or hepatitis 2, 4
• Non-malignant infiltrative liver disease, such as sarcoidosis or amyloidosis 2, 3
• Obstructive biliary diseases, such as cholangiocarcinoma or common bile duct stone 4, 3
• Sepsis, including gram-negative or gram-positive bacterial infections, or fungal sepsis 3
• High bone turnover, particularly in postmenopausal women with osteoporosis 5
• Certain types of cancer, such as pancreatic, lung, or colorectal cancer, which may have abnormal ALP expression or activity 6

Diagnostic Approaches

To diagnose the cause of elevated ALP levels, the following approaches can be taken:

• Medical history and physical examination to identify underlying conditions or symptoms
• Laboratory tests, such as liver function tests, bone metabolic markers, or tumor markers, to help identify the cause of elevated ALP levels 2, 5, 6
• Imaging studies, such as ultrasound, CT, or MRI, to evaluate the liver, bones, or other organs for potential abnormalities 2, 4, 3

Treatment and Management

Treatment and management of elevated ALP levels depend on the underlying cause:

• If caused by underlying malignancy, treatment may involve chemotherapy, radiation, or surgery 2, 6
• If caused by bone disease, treatment may involve bisphosphonates or other medications to manage bone turnover 5
• If caused by liver disease, treatment may involve medications to manage liver function or surgery to relieve obstruction 4, 3
• If caused by sepsis, treatment may involve antibiotics or other medications to manage the underlying infection 3