Interpret the laboratory findings, including mild anemia with low mean corpuscular hemoglobin (MCH) and low mean corpuscular hemoglobin concentration (MCHC), slight thrombocytopenia, and normal iron studies, in a 75‑year‑old patient taking rosuvastatin (Crestor) 40 mg, empagliflozin 25 mg, tirzepatide (Mounjaro) 12.5 mg weekly, azelastine (Astepro) 137 µg intranasally as needed, and lisinopril 5 mg.

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Laboratory Interpretation: Mild Anemia with Low Red Cell Indices and Borderline Thrombocytopenia

This 75-year-old patient has mild normocytic anemia with low MCH and MCHC, borderline thrombocytopenia, and normal iron studies—findings that do not indicate iron deficiency but warrant investigation for medication effects and underlying chronic disease, particularly given the patient's cardiovascular risk profile and current medications.

Key Laboratory Abnormalities

Anemia Profile

  • Hemoglobin 12.5 g/dL (low-normal for men; WHO defines anemia as <13.0 g/dL in men) 1
  • MCH 25.2 pg (low; reference 26.6-33.0)
  • MCHC 30.7 g/dL (low; reference 31.5-35.7)
  • MCV 82 fL (normal; reference 79-97)
  • RDW 13.8% (normal; reference 11.7-15.4)

The low MCH and MCHC with normal MCV creates a diagnostic pattern that is not classic iron deficiency anemia. True iron deficiency typically presents with low MCV (microcytosis) alongside low MCH and MCHC 1, 2. The normal MCV here suggests either early iron deficiency, functional iron deficiency, or anemia of chronic disease.

Iron Studies: Normal and Reassuring

  • Ferritin 95 ng/mL (normal; reference 15-150)
  • Iron saturation 23% (normal; reference 15-55%)
  • TIBC 302 µg/dL (normal)
  • Transferrin 251 mg/dL (normal)

These iron parameters are definitively normal and rule out absolute iron deficiency 3. In the context of chronic disease or inflammation, ferritin <100 µg/L with transferrin saturation <20% would suggest functional iron deficiency 3, but this patient's values exceed both thresholds.

Platelet Count: Borderline Low

  • Platelets 143 × 10³/µL (slightly low; reference 150-450)

This mild thrombocytopenia is clinically insignificant at this level but warrants monitoring. Rosuvastatin (Crestor) has rare associations with thrombocytopenia 4, though this is uncommon.

Inflammatory Markers: Negative

  • ESR 2 mm/hr (normal; reference 0-40)
  • CRP <1 mg/L (normal; reference 0-10)

The absence of inflammation makes anemia of chronic disease less likely and confirms that ferritin is not falsely elevated as an acute-phase reactant 3.

Glycemic Control and Renal Function

  • HbA1c 6.9% (elevated; reference 4.8-5.6%)—indicates suboptimal diabetes control
  • Albumin/creatinine ratio 5 mg/g (normal; reference 0-29)—no significant proteinuria
  • No serum creatinine provided, but the normal albumin/creatinine ratio suggests preserved renal function

Medication-Related Considerations

Rosuvastatin (Crestor 40 mg)

Recent evidence suggests statins may be associated with anemia 5. A 2025 Mendelian randomization study found that while genetic upregulation of HMGCR (statin target) reduced anemia risk, actual statin therapy was associated with increased anemia risk (OR 1.624,95% CI 1.307-2.018) 5. The mechanism remains unclear but warrants consideration in this patient.

Lisinopril (5 mg)

ACE inhibitors are well-documented causes of mild anemia through suppression of erythropoietin production 6. The magnitude is typically small (0.3-0.5 g/dL reduction in hemoglobin) but can be clinically relevant in older adults with borderline anemia 6.

Empagliflozin (25 mg)

Paradoxically, SGLT2 inhibitors like empagliflozin typically increase hemoglobin and hematocrit through hemoconcentration and enhanced erythropoietin secretion 7. This patient's mild anemia exists despite empagliflozin, suggesting the medication is not contributory and may actually be mitigating more severe anemia from other causes.

Tirzepatide (Mounjaro 12.5 mg)

No direct hematologic effects are documented in the FDA label 8. The drug is well-tolerated in geriatric patients with no specific anemia-related warnings 8.

Clinical Interpretation and Differential Diagnosis

Most Likely Diagnosis: Multifactorial Mild Anemia

  1. ACE inhibitor effect (lisinopril)—most common cause of mild normocytic anemia in this setting 6
  2. Possible statin contribution (rosuvastatin)—emerging evidence suggests association 5
  3. Age-related decline in erythropoiesis—common in older adults
  4. Suboptimal diabetes control (HbA1c 6.9%)—chronic hyperglycemia can impair erythropoiesis

What This Is NOT:

  • Not iron deficiency anemia: Normal ferritin (95 ng/mL) and iron saturation (23%) definitively exclude this 3
  • Not anemia of chronic disease: Normal CRP and ESR argue against active inflammation 1
  • Not chronic kidney disease-related anemia: Normal albumin/creatinine ratio and absence of significant proteinuria make advanced CKD unlikely 3

Recommended Management Approach

Immediate Actions: None Required

The hemoglobin of 12.5 g/dL is mild anemia that does not require urgent intervention. The patient is not transfusion-dependent and has no symptoms documented.

Monitoring Strategy

  1. Repeat CBC in 3 months to assess trajectory 3
  2. Obtain serum creatinine and eGFR to definitively rule out CKD (not provided in current labs)
  3. Monitor platelet count given borderline thrombocytopenia (143 × 10³/µL)
  4. Check vitamin B12 and folate if anemia worsens or MCV increases 1, 2

Medication Review

  • Consider reducing lisinopril dose if blood pressure allows—ACE inhibitors are dose-dependently associated with anemia 6
  • Continue empagliflozin—this medication likely provides protective hematologic effects 7
  • Monitor for statin-related anemia—consider checking hemoglobin before and after any statin dose changes 5
  • Optimize diabetes control (current HbA1c 6.9%)—better glycemic control may improve erythropoiesis

When to Investigate Further

Pursue gastrointestinal evaluation (upper endoscopy and colonoscopy) if 3:

  • Hemoglobin drops below 11 g/dL
  • Iron studies become abnormal (ferritin <100 ng/mL or iron saturation <20%)
  • Patient develops GI symptoms (bleeding, weight loss, abdominal pain)
  • Anemia progresses despite medication adjustments

In a 75-year-old, the threshold for GI investigation should be lower given higher malignancy risk, but current findings do not mandate immediate endoscopy 3.

Common Pitfalls to Avoid

  1. Do not empirically treat with iron: Normal ferritin and iron saturation mean iron supplementation is unnecessary and potentially harmful (iron overload risk) 3

  2. Do not overlook medication effects: ACE inhibitors and statins are underrecognized causes of mild anemia in older adults 5, 6

  3. Do not assume CKD without creatinine: While empagliflozin and lisinopril suggest cardiovascular/renal risk, the normal albumin/creatinine ratio argues against advanced CKD—obtain eGFR to confirm 3

  4. Do not ignore borderline thrombocytopenia: While 143 × 10³/µL is not dangerous, it warrants monitoring for progression, especially on rosuvastatin 4

  5. Do not over-investigate stable mild anemia: In an older adult with plausible medication-related causes and normal iron studies, aggressive workup is not immediately indicated—serial monitoring is appropriate 3

Summary of Key Points

  • Mild normocytic anemia (Hb 12.5 g/dL) with low MCH/MCHC but normal iron studies
  • Most likely causes: ACE inhibitor effect (lisinopril), possible statin contribution (rosuvastatin), age-related decline
  • Not iron deficiency: Ferritin 95 ng/mL and iron saturation 23% are normal
  • No immediate intervention required: Monitor CBC in 3 months, obtain creatinine/eGFR, optimize diabetes control
  • Consider medication adjustment: Reduce lisinopril if feasible; continue empagliflozin (protective effect)
  • GI investigation not currently indicated: Reserve for worsening anemia, abnormal iron studies, or GI symptoms

References

2
Guideline

clinical practice guidelines for evaluation of anemia.

Kidney International Supplements, 2008

4
Research

Rosuvastatin-induced thrombocytopenia.

Southern medical journal, 2010

6
Research

Antihypertensive medications and anemia.

Journal of clinical hypertension (Greenwich, Conn.), 2007

7
Research

Beneficial effects of empagliflozin on hematocrit levels in a patient with severe anemia.

Daru : journal of Faculty of Pharmacy, Tehran University of Medical Sciences, 2021

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