What is the diagnosis and recommended treatment for a patient with a hemoglobin A1c (HbA1c) level of 5.7%, indicating an increased risk for diabetes, and abnormal complete blood count (CBC) results showing low hemoglobin and hematocrit levels, suggesting possible anemia?

Diagnosis and Management of Prediabetes with Concurrent Anemia

Primary Diagnosis: Prediabetes

This patient has prediabetes based on an HbA1c of 5.7%, which places them at the lower threshold of the 5.7-6.4% prediabetes range defined by the American Diabetes Association. 1, 2

• The HbA1c of 5.7% indicates a 9-25% risk of developing diabetes within 5 years 1, 3
• This patient requires immediate lifestyle intervention counseling to prevent progression to diabetes 1
• Confirmation testing is not required for prediabetes diagnosis, unlike diabetes diagnosis which requires two abnormal tests 1, 2

Secondary Diagnosis: Mild Anemia

The patient has mild anemia with hemoglobin 11.9 g/dL (reference 12.0-15.0 g/dL) and low MCH (25.9 pg) and MCHC (27.5 g/dL), suggesting possible iron deficiency anemia or other microcytic process.

Critical Caveat: Impact of Anemia on HbA1c Interpretation

Iron deficiency anemia can falsely elevate HbA1c levels, potentially overestimating glycemic burden. 4

• The relationship between hemoglobin and HbA1c is well-established, with IDA causing spuriously elevated HbA1c values 4
• In this patient with borderline HbA1c (5.7%) and concurrent anemia, the true glycemic status may be lower than measured 4
• However, the anemia is mild (Hb 11.9 g/dL) and unlikely to cause clinically significant HbA1c elevation at this level 4

Recommended Management Algorithm

Step 1: Confirm Prediabetes Status with Glucose Testing

Obtain fasting plasma glucose (FPG) to confirm prediabetes diagnosis given the concurrent anemia. 2, 4

• FPG 100-125 mg/dL confirms prediabetes (IFG) 1
• FPG <100 mg/dL suggests the HbA1c may be falsely elevated by anemia 4
• The current glucose of 85 mg/dL is normal, but this was not necessarily a fasting sample based on the lab report 1

Step 2: Evaluate and Treat Anemia

Complete iron studies (serum iron, ferritin, TIBC, transferrin saturation) to determine anemia etiology. 4

• If iron deficiency is confirmed, initiate oral iron supplementation 4
• Recheck HbA1c 3 months after anemia correction to determine true glycemic status 4
• Do not set aggressive glycemic targets until anemia is corrected, as HbA1c may be falsely elevated 4

Step 3: Initiate Intensive Lifestyle Intervention Immediately

Counsel the patient on weight loss (if overweight) and physical activity to reduce diabetes risk by 58%, regardless of anemia status. 1

• Target 7% body weight loss through caloric restriction 1
• Recommend 150 minutes per week of moderate-intensity physical activity 1
• Interventions should be most intensive for those with HbA1c >6.0%, but this patient at 5.7% still requires active intervention 1

Step 4: Screen for Cardiovascular Risk Factors

Evaluate blood pressure and lipid panel (already obtained) as cardiovascular disease risk is elevated even in prediabetes. 1

• Current lipid panel shows optimal LDL 73 mg/dL and total cholesterol 159 mg/dL 1
• Sodium is mildly elevated at 147 mmol/L (reference 135-145), which requires follow-up 1
• Alkaline phosphatase is elevated at 130 U/L (reference 34-104), warranting further evaluation for hepatobiliary or bone disease 1

Step 5: Establish Monitoring Schedule

Recheck HbA1c annually to monitor for progression to diabetes, or sooner (3-6 months) if anemia is treated. 1

• Annual screening is appropriate for prediabetes at the lower end of the range (5.7%) 1
• More frequent monitoring (every 3-6 months) is warranted if HbA1c approaches 6.0% or if significant risk factors are present 1

Additional Laboratory Abnormalities Requiring Attention

Elevated White Blood Cell Count

• WBC 11.1 × 10³/uL (reference 3.8-10.8) with absolute neutrophilia (7.36 × 10³/uL, reference 1.5-6.5) suggests possible infection, inflammation, or stress response 1
• Clinical correlation needed to determine significance 1

Elevated Alkaline Phosphatase

• ALP 130 U/L (reference 34-104) requires differentiation between hepatic and bone sources 1
• Consider GGT or bone-specific ALP to determine origin 1

Mild Hypernatremia

• Sodium 147 mmol/L (reference 135-145) may indicate dehydration or other fluid/electrolyte disturbance 1
• Assess hydration status and recheck if persistent 1

Common Pitfalls to Avoid

• Do not ignore the anemia when interpreting HbA1c results, as iron deficiency can falsely elevate values 4
• Do not delay lifestyle intervention while investigating anemia, as preventive strategies should begin immediately 1
• Do not use HbA1c alone for diagnosis if conditions affecting red blood cell turnover are present 1, 2
• Do not assume HbA1c 5.7% represents negligible diabetes risk—this patient has 3-8 times higher risk than the general population 1, 3