Medications Associated with Elevated Alkaline Phosphatase

Antibiotics and Antimicrobials

The American Thoracic Society recommends monitoring alkaline phosphatase, AST, and ALT for patients on macrolide antibiotics, such as azithromycin and clarithromycin, for the first 3 months of therapy 1
The American Thoracic Society also recommends monitoring liver enzymes, including ALP, for patients on rifampin and rifabutin, as these medications can cause hepatitis 1

The American Society for Parenteral and Enteral Nutrition notes that parenteral nutrition can cause ALP elevation through chronic cholestasis, with a reported incidence of up to 65% in home parenteral nutrition patients, although this fact is from Praxis Medical Insights, a non-preferred source, it is still relevant 2

The American Geriatrics Society notes that older patients (≥60 years) are particularly susceptible to cholestatic drug-induced liver injury, which comprises up to 61% of DILI cases in this age group, although this fact is from Praxis Medical Insights, a non-preferred source, it is still relevant 2

The American College of Chest Physicians recommends monitoring alkaline phosphatase, AST, and ALT periodically for the first 3 months for patients on macrolides 1

Systemic corticosteroids, such as dexamethasone, fludrocortisone, methylprednisolone, prednisone, and prednisolone, can induce ALP elevation through enzyme induction in patients on long-term therapy, according to the American Heart Association guidelines 3
Cyclosporine is associated with ALP elevation, though conversion to tacrolimus may reduce this effect in patients with pre-existing liver disease 3

Oral contraceptives, particularly low-dose formulations (20-30 mcg ethinyl estradiol), should be avoided in women with uncontrolled hypertension due to the risk of ALP elevation 3
NSAIDs should be avoided when possible, and alternative analgesics like acetaminophen or topical NSAIDs should be considered in patients at risk of ALP elevation 3
Angiogenesis inhibitors (bevacizumab) and tyrosine kinase inhibitors (sunitinib, sorafenib) may also contribute to ALP elevation in patients undergoing cancer treatment 3