From:  Hypophosphatasia: current concepts in diagnosis and management of a rare metabolic disorder

 Conditions associated with low and elevated ALP levels in the evaluation of hypophosphatasia.

CategoryLow ALP levelsHigh ALP levels
Drugs and substances
  • Antiresorptives: denosumab, bisphosphonates

  • Vitamin D toxicity

  • Chemotherapy

  • Clofibrate

  • Antibiotics: amoxicillin/clavulanate, oxypenicillins, macrolides, sulfonamides

  • Antivirals: particularly antiretroviral therapy, e.g., protease inhibitors

  • Anticonvulsants: carbamazepine, phenytoin, valproic acid

  • Cardiovascular drugs: captopril, verapamil, diltiazem, quinidine

  • Psychotropics: monoamine oxidase inhibitors, chlorpromazine, fluoxetine, risperidone

  • DMARDs: methotrexate, penicillamine

  • Anti-tuberculosis: isoniazid, pyrazinamide, rifampicin, rifabutin

  • Antidiabetics: sulfonylureas, glipizide

  • Others: estrogens, anabolic steroids, alcohol, cocaine

Medical conditions
  • Metabolic bone diseases: achondroplasia, cleidocranial dysplasia, osteogenesis imperfecta type II, Mseleni joint disease, renal osteodystrophy (adynamic bone disease)

  • Endocrine: hypoparathyroidism, hypothyroidism

  • Metabolic/systemic: Wilson’s disease, haemochromatosis

  • Genetic: benign familial hypophosphatemia

  • Surgery: cardiac bypass surgery, major surgery

  • Vitamin deficiencies: vitamin C, Mg, Zn

  • Others: celiac disease, milk-alkali syndrome, pernicious anemia, profound anemia, severe illness, myeloma, trauma, massive transfusions, malnutrition, any disorder that impairs linear growth in children, radioactive heavy metal intoxication

  • Bone conditions: growth spurts in adolescents, healing fractures, osteomalacia, Paget’s bone disease, osteosarcoma

  • Endocrine: hyperparathyroidism, hyperthyroidism, subacute thyroiditis

  • Liver conditions: cholestasis, primary sclerosing cholangitis, hepatitis, cirrhosis, liver tumors

  • Tumors: lung, gastric, head and neck

  • Others: infections, pregnancy, gastric ulcer disease, total parenteral nutrition

Technical factorsBlood collection tubes containing EDTA, citrate, or oxalate

The table is based on the references [5, 9, 10, 13, 20, 3540]. ALP: alkaline phosphatase; DMARDs: disease-modifying antirheumatic drugs; EDTA: ethylenediaminetetraacetic acid.