Pioglitazone is an oral hypoglycemic drug from the thiazolidinedione drug class, FDA approved for the treatment of diabetes mellitus type 2 (DM-2) in adults, as an adjunct to diet and exercise.
DM is a chronic metabolic illness with prevalence trends steadily rising worldwide. It is predicted that the prevalence of DM (especially DM-2) will increase in the next two decades, more so in developing nations within the adult population aged between 45 and 64 years. The need to maintain blood glucose levels is critical to prevent the progression of this disease and its complications. The American Diabetes Association (ADA) has a set goal of HbA1C less than 7% in most non-pregnant patients, a stricter goal of less than 6.5% in some patient groups, or a less strict one of less than 8% in others, based on subjective patient characteristics.
Thiazolidinediones (TZDs) are the first drugs to address the fundamental problem of insulin resistance in type 2 DM patients; the class includes pioglitazone and rosiglitazone. (The FDA restricted the use of rosiglitazone due to increased cardiovascular events reported with it). A randomized, double-blind, placebo-controlled, clinical trial of the effects of pioglitazone on glycemic control and dyslipidemia in oral antihyperglycemic medication-naive patients with DM-2 demonstrated immense improvements in HbA(1c), insulin sensitivity, and lipid profile.
The mechanism through which TZDs exert their anti-diabetic effect is augmenting insulin sensitivity. This action involves the activation of a nuclear receptor, the gamma isoform of peroxisome proliferator-activated receptor (PPAR-gamma ). The activation of this nuclear receptor, in turn, alters the gene transcription of several genes involved in glucose and lipid metabolism, along with energy balance. These genes include those for fatty acid transporter protein, lipoprotein lipase, glucokinase, and the GLUT4 glucose transporter. TZDs help to reduce insulin resistance in muscle, liver, and adipose tissues. Since PPAR-gamma concentrates heavily in adipose tissue, the effect on muscle and liver seems to be via endocrine signaling from adipocytes. The exact mechanism of action of TZDs is still not entirely clear, but they have been proven to potentially improve the insulin resistance syndrome and the complications of DM-2.
Pioglitazone is taken orally, with or without food. Can be taken as monotherapy, but is usually used as an addition to metformin/sulfonylurea or insulin therapy.
For adults, the dose starts initially at 15 mg or 30 mg orally once daily. For those who respond inadequately, dose increments of 15 mg of the drug are appropriate as needed. The maximum permissible dose is 45 mg/day by mouth every day.
Adults who do not have symptomatic heart disease, but possess any risk factors for congestive heart failure, or those belonging to NYHA Class I or II heart failure category, the recommended dose is no more than 15 mg orally once daily.
The common adverse effects of pioglitazone are edema, weight gain, macular edema, and congestive heart failure (CHF). It may cause hypoglycemia when combined with other antidiabetic drugs, as well as decrease hematocrit and hemoglobin levels.
There is a known drug interaction with oral contraceptives (OCPs), as co-administration of a TZD with OCPs containing Ethinyl estradiol and norethindrone reduced the plasma concentrations of both hormones by approximately 30%, which could result in loss of contraception. Therefore, ensure extra caution regarding contraception in patients receiving pioglitazone and OCPs.
Contraindications to the use of pioglitazone include the following scenarios:
There is no known antidote for pioglitazone overdose; the only treatment in such cases is supportive management.
Healthcare workers in all capacities dealing with DM-2 patients on pioglitazone should be aware of the dosage and adverse effects of the drug. This medication requires an interprofessional team due to potential adverse effects, as well as monitoring for therapeutic effectiveness. The team should educate the patient about the possible side effects, and the importance of considering the drug to be an adjunct to lifestyle and dietary changes. Patients should be aware of regular monitoring with blood glucose, HbA1C, and liver function tests, and encouraged to inform doctors of any signs of heart failure or dermatologic reactions.
When a clinician initiates pioglitazone therapy, they do not do so in a vacuum. A pharmacist should collaborate to verify that there are no drug interactions, that dosing is appropriate, and, as mentioned above, offer patient counsel. A certified diabetes educator nurse is also invaluable, as they can help the patient coordinate the administration and monitoring of the diabetes drug regimen, and report to the prescriber any issues that may arise. Pioglitazone therapy requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]
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