How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?

There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.