Raised alkaline phosphatase
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Raised ALP in adults: liver or bone?
Fasting laboratory tests
- Alkaline phosphatase (fasting follow-up)
- GGT
- AST
- ALT
- Bilirubin
Also consider
Do not order
- Bone ALP or isoenzymes straight away: GGT is usually enough to decide the origin; isoenzyme electrophoresis is reserved for persistent doubt [2]
Raised ALP, normal GGT (probable bone origin)
Fasting laboratory tests
- Serum calcium
- Serum albumin
- Serum phosphate
- 25-hydroxyvitamin D (reimbursed in France) (suspected osteomalacia, to be stated on the request)
- Serum creatinine with eGFR
- TSHif needednon-French guidelineClinical signs of hyperthyroidism: hyperthyroidism is one of the non-hepatic causes of raised ALP [3].
- PTH (raised serum calcium: search for a parathyroid adenoma; on the same sample as the serum calcium)if neededRaised calcium: look for hyperparathyroidism (parathyroid adenoma), a cause of raised ALP [3,4]. Reimbursed in this case, since the question asked is the diagnosis of a parathyroid adenoma (code 0983) [4].
- If Paget's disease suspected: X-rays (abdomen, skull, facial bones, tibiae) and bone scan (not laboratory tests).
Do not order
Sources (6)
- Donnan PT, McLernon D, Dillon JF, et al. Development of a decision support tool for primary care management of patients with abnormal liver function tests without clinically apparent liver disease: a record-linkage population cohort study and decision analysis (ALFIE). Health Technol Assess. 2009;13(25):iii-iv, ix-xi, 1-134.
- Newsome PN, Cramb R, Davison SM, et al. Guidelines on the management of abnormal liver blood tests (British Society of Gastroenterology). Gut. 2018;67(1):6-19.
- Kwo PY, Cohen SM, Lim JK. ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol. 2017;112(1):18-35.
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 1139 (25-OH vitamine D) et 0983 (parathormone).
- Ralston SH, Corral-Gudino L, Cooper C, et al. Diagnosis and Management of Paget's Disease of Bone in Adults: A Clinical Guideline. J Bone Miner Res. 2019;34(4):579-604.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol. 2009;51(2):237-67, section 9, tableau 5.