Pioglitazone

Aka: Pioglitazone, Actos

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II. Indications

  1. Pioglitazone is preferred of the Glitazones
    1. Vascular disease risk increase with Rosiglitazone
  2. Oral Hypoglycemic for Type II Diabetes Mellitus
    1. Second line agent (although falling out of favor in 2012 due to risks)
    2. Add to other Oral Hypoglycemic agents
  3. Diabetes with coronary Vasospastic Angina pectoris
    1. Murakami (1999) Am J Cardiol 84:92-4 [PubMed]
  4. Insulin Resistance Syndromes (experimental)
    1. Polycystic Ovary Syndrome
  5. Psoriasis (experimental)
    1. Thiazolidinediones activate PPARs
      1. Peroxisome proliferator-activated receptors (PPARs)
    2. PPARs have antiinflammatory activity in Psoriasis
      1. Ellis (2000) Arch Dermatol 136(5):609-16 [PubMed]

III. Contraindications

  1. Type 1 Diabetes Mellitus
  2. Liver disease (ALT > 2.5x upper limit of normal)
  3. CHF NYA Class III or Class IV Heart Failure
  4. Osteoporosis or Osteopenia
  5. Bladder Cancer

IV. Precautions

  1. CHF exacerbation risk (and contraindicated for NYHA Class III or IV) for ALL Glitazones (FDA Black Box warning)

V. Mechanism

  1. Thiazolidinedione derivative
  2. Primary mechanism: Increases peripheral tissue Insulin sensitivity
  3. Secondary mechanism: Decreases hepatic Glucose production
  4. Acts at liver, skeletal Muscle and fat cells
  5. Activates peroxisome proliferator activated receptors
    1. Receptors known as PPARS
    2. Reduces Insulin Resistance
    3. May independently reduce Cardiovascular Risk
    4. Increases Glucose uptake
    5. Decreases hepatic Glucose output
  6. Shifts fat deposition from visceral to subcutaneous
  7. Decreases free Fatty Acid levels

VI. Medications

  1. Pioglitazone (Actos) 15 mg, 30 mg, 45 mg

VII. Dosing

  1. Protocol
    1. Discontinue if no improvement in diabetes control within 8 to 12 weeks
  2. Dosing
    1. Start: 15 to 30 mg orally daily for the first 3 months
    2. Maximum: 45 mg per day

VIII. Adverse Effects

  1. Hepatotoxicity and Liver Failure
    1. Associated with Troglitazone use
    2. Troglitazone removed from U.S. market in March 2000
    3. Rosiglitazone and Pioglitazone may also cause this
    4. Follow Liver Function Tests closely
      1. Especially follow in first year
    5. References
      1. May (2002) Ann Intern Med 136:449-52 [PubMed]
  2. Fluid retention
    1. Congestive Heart Failure risk (see below)
    2. Peripheral Edema (in 3-5% of patients)
    3. Moderate weight gain (1-3 kg)
    4. Mild Anemia
  3. Variable lipid effects
    1. Pioglitazone (Actos)
      1. Lowers Triglycerides by 9-12%
      2. Raises HDL Cholesterol by 12-19%
    2. Rosiglitazone (Avandia):
      1. RAISES Triglycerides by 15%
      2. Raises HDL Cholesterol by 8-19%
      3. Raises LDL Cholesterol
    3. References
      1. (2005) Prescriber's Letter 12(8):43
  4. Risks of adverse effects (compounded when combined with Insulin)
    1. Weight gain (3-4 kg)
    2. Edema (8-10% of cases)
    3. Congestive Heart Failure
      1. Observe patients with CHF risk closely
    4. Hypoglycemia risk
  5. Fracture Risk and Decreased Bone Density (Osteoporosis risk)
    1. Class effect
    2. Odds Ratio approaches 2.5 for Glitazone use >8 months
    3. (2008) Arch Intern Med 168:820-5 [PubMed]
  6. Cardiovascular Risk
    1. Rosiglitazone (Avandia) appears to increase CAD risk
      1. No longer recommended as a first-line agent
    2. Pioglitazone (Actos) may slightly decrease CAD risk
      1. Atherosclerosis may be slowed by Actos
      2. Nissen (2008) JAMA 299(13):1561-73 [PubMed]
  7. Bladder Cancer risk
    1. Risk of up to 11 per 10,000 cases per patients taking Pioglitazone (actos) >1 year
    2. Mamtani (2012) J Natl Cancer Inst 104 (18): 1411-1421 [PubMed]

IX. Pharmacokinetics

  1. Hepatic metabolism by Cytochrome P450: CYP2C8

X. Monitoring

  1. Liver Function Tests
    1. Initial: Baseline and in 6-12 weeks
    2. Later: Every 6 months
  2. Do not start medication if LFTs > 2.5x normal
  3. Stop medication if LFTs >3x normal
  4. Follow weight for weight gain (esp. if CHF risk)

XI. Efficacy

  1. Lowers Hemoglobin A1C 0.5 to 1.5%
  2. Delays Insulin need when added to Metformin, Sulfonylureas
    1. Aljabri (2004) Am J Med 116:230-5 [PubMed]
    2. Dailey (2004) Am J Med 116:223-9 [PubMed]

XII. Safety

  1. Unknown Safety in pregnancy
  2. Avoid in Lactation

XIII. Resources

  1. Pioglitazone (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=5e36173a-2b5f-4ed7-bf81-6e79d78df0c4

XIV. References

  1. (1999) Med Lett Drugs Ther 41(1059):71-3 [PubMed]
  2. Krische (2000) West J Med 173:54-7 [PubMed]
  3. Schwartz (1998) N Engl J Med 338:861-6 [PubMed]
  4. Saltiel (1996) Diabetes 45:1661-9 [PubMed]
  5. Vaughan (2024) Am Fam Physician 109(4): 333-42 [PubMed]

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Related Studies

Cost: Medications

pioglitazone (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
PIOGLITAZONE HCL 15 MG TABLET Generic $0.08 each
PIOGLITAZONE HCL 30 MG TABLET Generic $0.12 each
PIOGLITAZONE HCL 45 MG TABLET Generic $0.14 each
PIOGLITAZONE-METFORMIN 15-500 Generic $0.29 each
PIOGLITAZONE-METFORMIN 15-850 Generic $0.39 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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