Pathophysiology and Complications of Type 2 Diabetes

A clinical review of the pathophysiology and complications associated with type 2 diabetes.

Tripp Logan, PharmD: Type 2 diabetes is an interesting and really complex issue. And when our patients show up with type 2 diabetes, there are typically complex factors involved with that. So at its essence it’s a blood sugar issue, blood glucose elevated in the blood, and that causes all kinds of other problems. You can have cardiovascular problems, microvascular, macrovascular. But along with that, a lot of times diabetes brings other baggage. And so there are mental health issues, including depression. We’ve got cardiovascular disease, we’ve got issues with kidneys, renal issues, and it’s ongoing. And a lot of times with the patients who we see, they walk in and think it’s always just cause and effect. “I eat this, my blood sugar goes up, and I’ve got diabetes; I don’t eat that, and it goes away.” But it’s so complex, with so many mechanisms of pathways, that it’s just not that simple to treat. And so as complex as the current condition is, it’s even more complex to treat. And it all starts with education, ensuring that patients understand exactly what’s going on with their bodies. And if they understand that it’s not always just immediate cause and effect, then a lot of times it makes it easier for us to help them treat their condition down the road.

In diabetes there are microvascular and macrovascular concerns. Micro basically means small blood vessels. And when we look at small blood vessels, you’re thinking in the eyes, the kidneys, the extremities. A lot of times these things pop up with patients, and those are the symptoms that they present with, at least with us. We’ll see numbness in the extremities. We’ll see issues that were presenting based on blood work that they’ve had in a routine medical exam. Those are really big concerns when we look at long-term effective diabetes. Blood sugar circulating through the blood is particularly aggressive to those blood vessels. And when that blood sugar is elevated over time, patients end up having issues with those very, very small blood vessels because they’re damaged. And over a period of months to years that can be really devastating.

On the macrovascular side, patients who have routinely high blood sugar levels in their blood, circulating can really cause problems to large blood vessels, specifically around the heart, and it puts you at high risk for cardiovascular events like heart attack and stroke. So having diabetes, having high blood sugar, having high levels of glucose in the blood, that puts you at risk for a lot of other things and not the least of which would be a heart attack or a stroke.

Treating type 2 diabetes is really complex, and when pharmacists are presented with patients who have type 2 diabetes, to me the most important thing to relay to them is this is going to be an ongoing journey. A new prescription, a tablet and injection, a new therapy, a little bit of exercise—that’s not going to completely solve this issue.

So today is the first day of a journey, and that journey is something that has a lot of bumps and twists and turns, something that is a concern, but it can absolutely be managed and be treated, and positive outcomes can occur. It’s a journey that needs to include family, everybody in the house. Health care providers, support systems. Then you get into out-of-pocket concerns. Patients have a budget, and most of them are already outside their budget before they have the cost of diabetes medication. So lots of complicating factors with this diabetes journey.

But when patients present to us and they say, “I’ve got diabetes. This is my new prescription. What do I do? Do I cut out all foods that are white? Do I completely change my diet?” It’s a step-by-step approach that’s typically the best. And looking at this as a long journey that is 1 step at a time with 1 change at a time, and not trying to do too much too quickly, is typically when we’ve seen the best positive results from patients that we care for.