Makindo Medical Notes

✅ Low hypoglycaemia risk when used alone (hypos mainly if combined with insulin / sulfonylurea). Often used as 2nd/3rd-line (triple) therapy to delay or avoid insulin, where appropriate.

About

• Always verify dosing, contraindications, and monitoring in the BNF (pioglitazone) .
• Remember: benefits can take several weeks; review response rather than expecting rapid HbA1c change.

Mode of action

• Thiazolidinedione (TZD); activates PPAR-γ → ↑ insulin sensitivity in adipose tissue, liver, and muscle.
• Improves peripheral glucose uptake and reduces hepatic glucose output (so helps insulin resistance).
• Can cause fluid retention (mechanistic) → key reason for HF caution/contraindication.

Indications

• Type 2 diabetes as add-on therapy when glycaemic targets not met (e.g., with metformin; or with metformin + sulfonylurea; or with insulin in selected patients).
• Best suited to people with prominent insulin resistance where weight gain/oedema risk is acceptable.

Dose

• 15–30 mg once daily, adjust to 45 mg once daily according to response and tolerability.
• Elderly/frail: start at the lowest dose, uptitrate cautiously, and reassess benefit vs harms early.
• Review at 3–6 months: stop if inadequate glycaemic response.

Interactions

• Check BNF for full list.
• CYP2C8 inhibitors (e.g. gemfibrozil) can ↑ pioglitazone levels; CYP inducers (e.g. rifampicin) can ↓ effect.
• If used with insulin or sulfonylurea, consider dose reduction of those agents to reduce hypoglycaemia risk.

Monitoring

• LFTs: check before starting; repeat if symptomatic or per BNF/local policy (stop if significant ALT rise).
• Fluid status: weight gain, oedema, new/worsening breathlessness (HF red flags).
• Fracture risk: especially post-menopausal women/older adults.
• Vision: ask about visual change (rare macular oedema).

Contraindications

• Heart failure (or history of heart failure) / significant fluid overload.
• Other important exclusions exist — confirm in BNF (e.g. hepatic disease, bladder cancer risk factors).

Adverse effects

• Weight gain, oedema, and possible heart failure exacerbation.
• Increased fracture risk (class effect).
• Visual disturbance (rare macular oedema), infections, anaemia.

References

• BNF: Pioglitazone

Revisions