From the Guidelines
The evaluation and management approach for an adult with elevated alkaline phosphatase (alk phos) levels should begin with a thorough history, physical examination, and assessment of other liver function tests to determine the source, as recommended by the most recent guidelines 1. The approach to elevated ALP in adults involves determining if the elevation is isolated or accompanied by other liver test abnormalities. If other liver tests are abnormal, the focus should be on hepatobiliary causes; if ALP is isolated, consider bone sources or other conditions.
- Initial workup should include:
- Gamma-glutamyl transferase (GGT) or 5'-nucleotidase to confirm hepatic origin
- Complete blood count
- Comprehensive metabolic panel
- Hepatitis serologies
- Imaging studies like ultrasound, CT, or MRI of the liver should be performed to evaluate for biliary obstruction, masses, or infiltrative diseases.
- If bone origin is suspected, bone-specific ALP isoenzyme testing, vitamin D levels, parathyroid hormone, and bone imaging may be appropriate.
- For persistent unexplained elevations, consider less common causes like medication effects, infiltrative liver diseases, or rare genetic conditions. Management depends on identifying and treating the underlying cause, which might include addressing biliary obstruction, treating underlying liver disease, discontinuing offending medications, or managing bone disorders, as supported by recent studies 1. Regular monitoring of ALP levels is recommended during treatment to assess response, and the most recent guidelines emphasize the importance of a thorough initial evaluation to guide further management 1.
From the Research
Evaluation Approach
The evaluation of an adult with elevated alkaline phosphatase (alk phos) levels involves a comprehensive approach to determine the underlying cause. The following steps can be taken:
- Obtain a thorough medical history to identify any underlying conditions that may be contributing to the elevated alk phos levels 2, 3, 4, 5
- Perform a physical examination to look for signs of liver disease, bone disease, or other conditions that may be associated with elevated alk phos levels 2, 3, 4, 5
- Order laboratory tests, such as liver function tests, bone alkaline phosphatase, and other tests as needed, to help determine the cause of the elevated alk phos levels 2, 3, 4, 5
Common Causes of Elevated Alk Phos
The common causes of elevated alk phos levels in adults include:
- Bone disease, such as Paget's disease or osteomalacia 2, 3, 4
- Liver disease, such as cirrhosis or cholestasis 2, 3, 4, 5
- Malignancy, such as liver or bone cancer 2, 3, 4, 5
- Sepsis or other infections 2, 4
- Biliary obstruction 2, 4
- Other conditions, such as hyperthyroidism or hypothyroidism 5
Management Approach
The management of an adult with elevated alk phos levels depends on the underlying cause. The following steps can be taken:
- Treat the underlying condition, such as liver disease or bone disease, to help reduce alk phos levels 2, 3, 4, 5
- Monitor alk phos levels regularly to assess the effectiveness of treatment 2, 3, 4, 5
- Consider referral to a specialist, such as a hepatologist or an endocrinologist, if the underlying cause is unclear or if treatment is not effective 2, 3, 4, 5
Association with Other Conditions
Elevated alk phos levels have been associated with other conditions, such as: