“Race and gender (due to inherited or iron def. anemias) inequality using HbA1c?”
HbA1c is a hematology test, not an endocrinologist test. In " NIDDK ethnicities and A1c", it not only easily explains hemoglobinopathies, errors still being "made" by GPs" which in itself is inaccurate as it is the pathology labs who, by having fasting A1c will be able to inform the GP that any forms of anemia will show up as discordant A1c and fasting glucose results and therefore, the blood specialists will be responsible for stopping the GP errors in this Peer NIDDK Journal.
Male | 79 years old
Complaint duration: over 20 years, not medicated
Medications: Not medicated due to false A1c
Conditions: type 2 diabetes with low grade hemolytic anemia
3 Answers
Well, true, an HbA1c does not always accurately represent the status of a patient's diabetes. There are certain conditions such as anemia (could be due to premature destruction of red blood cells [hemolysis], or blood loss, or lack or adequate production of red blood cells) that would have lower HbA1cs than accurately reflects the degree of the patient's blood sugars. A fructosamine level can be used in these circumstances. With the advent of the continuous glucose monitors, physicians can get a better picture of the overall level of the blood sugars and can then make better decisions on the appropriate medications to prescribe. Certainly, proper diet and exercise are preferred for blood sugar control, but when that fails, medications are necessary. Control of high sugars is relevant in order to prevent strokes, heart attacks, amputations, kidney failure, complications of years of syrupy, sticky blood cells, even in people with anemia.
Yes, patients with low grade hemolytic anemia such as yourself will have falsely low A1c levels.
Things that can falsely lower A1c include:
Chronic Kidney disease
Mechanical Heart Valves
Sickle Cell Disease
Hemolytic Anemia
Blood loss (GI bleeds, etc)
Splenomegaly
There are also situations where A1c can be falsely elevated:
Things that can falsely elevate A1c:
Carbamylated hgb
Uremic Acidosis
Hgb F
Hypertriglyceridemia
Hyperbilirubinemia
Iron deficiency anemia
Opiate addiction
Lead poisoning
Alcoholism
High dose Aspirin
In the United States, if we suspect that A1c levels are discordant from actual blood sugars, we can do a professional CGM to get something called a GMI or “glucose management indicator” - this is what a patient’s A1c would be if their hemoglobin and rate of cell turnover were “normal”
We can treat based on the actual blood sugars and disregard the erroneous A1c.
Things that can falsely lower A1c include:
Chronic Kidney disease
Mechanical Heart Valves
Sickle Cell Disease
Hemolytic Anemia
Blood loss (GI bleeds, etc)
Splenomegaly
There are also situations where A1c can be falsely elevated:
Things that can falsely elevate A1c:
Carbamylated hgb
Uremic Acidosis
Hgb F
Hypertriglyceridemia
Hyperbilirubinemia
Iron deficiency anemia
Opiate addiction
Lead poisoning
Alcoholism
High dose Aspirin
In the United States, if we suspect that A1c levels are discordant from actual blood sugars, we can do a professional CGM to get something called a GMI or “glucose management indicator” - this is what a patient’s A1c would be if their hemoglobin and rate of cell turnover were “normal”
We can treat based on the actual blood sugars and disregard the erroneous A1c.
You are correct that the A1c may be discordant from the blood sugar and should not be used to base treatment. Conditions involved in this situation depend on race, ethnicity as well as multiple medical conditions such as hemolytic anemia with shortened red cell life span. In these situations, I use the venous plasma fasting sugar as well as the two hour post prandial capillary sugar to guide treatment. My goal is a fasting sugar below 120 and post prandial two hours below 180.
Respectfully,
Marvin A. Leder, MD FACP FACE
Respectfully,
Marvin A. Leder, MD FACP FACE
