Diabetic case discussion

Recently i had a discussion in MCPA forum regarding a diabetes case study. Since i dont have anything to post in my blog, i decided to paste the discussion here. If u r taking a lot of medicines and u think u want a medications counselling, pls email me your details.

Case study in MCPA
A 61 years old female with Type II diabetes. Most importantly is that she is obese with BMI of 34.5.
She has been taking:
Metformin 500mg, 1BD for 2-3 years
Simvastatin 40mg, 1ON for 2-3 years (It is for prevention of heart disease, as it is stated that diabetic patient with the age of over 40 years is at high risk of getting cardiovascular disease)
However, 3 months ago her blood glucose was measured high, which in this case, Gliclazide 80mg, 2OD was added on for her, so she's now under gliclazide ,metformin and simvastatin for three months so far.
She has the side-effect of diarrhoea from the medication she's on all this while though we don't know which medication is it.

Sulphonylureas are not recommended or suggested for overweight patient, therefore, what should we do about that?
How do we get rid of her diarrhoea problem with proper medication to control or maintain her blood glucose?
What are the alternatives for simvastatin or metformin if diarrhoea is coming from either of them?

Ask the pharmacist
My answer:
The most important thing is to reduce the microvascular complications.

Always check for HbA1C and target it to be less than 7%, go for lab
test.
Metformin is the main treatment in this case, esp becoz it doesn't
cause weight gain and with it alone can reduce up to 1.5% HbA1C.
She have not maximized her metformin dosage yet, ie 2tds. Can try
before using gliclazide. As for sulphonylureas, i will prefer minidiab
than gliclazide as it is shorter acting.

As for avandia, i will prefer Actos becoz i am concern for her lipid
profile and the risk of cardiovascular effect. But it is associated
with weight gain and also some fluid retention as well. Bear in mind
Avandia also cause osteoporosis since she is a lady.

I wont recommend acarbose as she already having diarrhea. Try to
identify the which medication cause the diarrhea by stopping it and
monitor. In between, i would advise her to take some probiotics and
also psyllium husk. Most probably is her metformin which causes the
diarrhea.

It is still the best if she can inject basal insulin at night. Start
with 10 units around 10pm and check her fasting glucose at 8am for 3
days. Increase 2-4 units if mean FBG is >7.2mmol/L

Lastly, as always, pls consult your doctor. .