Isolated Raised Alkaline Phosphatase - what to do?

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I go through a real-life case of an asymptomatic patient with an isolated raised alkaline phosphatase level. I will describe a recommended approach to investigate and manage them according to guidelines. I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement. There is a YouTube version of this and other videos that you can access here: · The NICE GP YouTube Channel: NICE GP - YouTube You can download a summary of my summary / interpretation of the guidance here: · My Summary: https://1drv.ms/b/s!AiVFJ_Uoigq0mC4pm_bYELFa9wEx?e=07p2dJ Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through TranscriptInterpreting Isolated Raised Alkaline Phosphatase in Asymptomatic PatientsHello and welcome. I’m Fernando, a GP in the UK. Today, we're going to explore what to do when we encounter an isolated raised serum Alkaline Phosphatase level in an asymptomatic patient. Please like and subscribe to support the channel. Right, so let's dive right in!IntroductionBefore we start, let’s remember that Alkaline Phosphatase is present in various tissues, including the liver, bone, kidney, intestine, and placenta. Reference ranges can vary with age and gender, so mild increases may not indicate disease.Examples of Physiological Causes are:· Growth spurts in adolescents· Pregnancy in women· Age-related increases and· Medications like some antibiotics, antiepileptics, antihistamines, oestrogens, and steroidsSome potential causes of isolated raised serum Alkaline Phosphatase include:· Congestive cardiac failure· Bone diseases · Hyperthyroidism· End-stage renal diseaseClinical caseSo, let’s have a look at our patient. She is a 49-year-old lady who had some blood tests because she was feeling a little tired. Her results came back normal with the exception of an alkaline phosphatase level of 186 (NR 30-130). Physical examination was normal and that there were no signs or symptoms of disease. In addition, she does not drink alcohol at all.What should be our next steps?The baseline investigations for someone with an isolated Alkaline Phosphatase are the following tests:· Liver function tests adding GGT· Calcium and phosphorus adding vit D and PTH · Renal and thyroid function tests and· A full blood countWe know that the most likely sources of Alkaline Phosphatase are either the bone or the liver. And, in order to differentiate between them, this is why we measure GGT (which is typically elevated in liver issues) and vitamin D levels and PTH levels, which may point towards bone causes.So, for this patient we will need to repeat the Alkaline Phosphatase levels and checking gamma-GT, vitamin D and parathyroid hormone to try to determine the cause, as well as making sure that the other tests, that is, renal, and thyroid function tests, calcium, phosphorus and a full blood count have also been checkedWe will talk more about our patient a little later but now let’s say that, in general terms, if all these tests come back normal, further investigations can be deferred for three months, during which Alkaline Phosphatase levels should be rechecked. Rechecking it earlier than three months is generally unnecessary unless you have specific concerns.If Alkaline Phosphatase is raised with elevated GGT levels, it's likely of hepatic origin. Further steps that we will need to consider include:· Abdominal ultrasound scan (to check for cholestasis and hepatic space-occupying lesions)· Antimitochondrial antibodies test (to explore the possibility of primary biliary cirrhosis) However, if these liver investigations are normal, and the Alkaline Phosphatase level is less than 1.5 times the upper reference limit, observation and monitoring every 3 to 6 months is recommended.However, if the Alkaline Phosphatase level is more than 1.5 times the upper reference limit and a hepatic origin is suspected, referral for further liver investigations is recommended.Now, if GGT levels are normal, the raised Alkaline Phosphatase is most likely from a non-hepatic source, often bone-related. This can be due to vitamin D deficiency, Paget's disease of bone, or growth spurts in adolescents.And how do we manage this? Obviously, if the vitamin D levels are low, we will treat the deficiency accordingly. And if there is any abnormality in the PTH levels, we will also manage it and investigate it further. If Vitamin D and PTH are normal and if the Alkaline Phosphatase level is less than 1.5 times the upper ...