Who Still Uses Pioglitazone in Type 2 Diabetes?
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Who Still Uses Pioglitazone in Type 2 Diabetes?
Discuss any aspect of type I or type II diabetes mellitus here
Dear Colleagues: Pioglitazone is restricted in some countries but is still legalized, and even well prescribed and recommended in other countries like the USA. Now came in the BMJ a well conducted an
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Forums » Open clinical » Diabetes » Who Still Uses Pioglitazone in Type 2 Diabetes?
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Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 21/6/2012 5:02 PM BST
on bmj.com
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Posts: 627
First: 13/4/2011 Last: 18/6/2013 |
Dear Colleagues: Pioglitazone is restricted in some countries but is still legalized, and even well prescribed and recommended in other countries like the USA. Now came in the BMJ a well conducted and controlled for potential biases study showing that this glitazone significantly increases the risk of one of the most dangerous types of cancers: Bladder cancer. "The use of pioglitazone and the risk of bladder cancer in people with type 2 diabetes: nested case-control study" BMJ 2012;344:e3645 doi: 10.1136/bmj.e3645 (Published 31 May 2012) For me, I have just seen enough with all the glitazone family in diabetes care. Any other Comments? All Best, Joey |
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 21/6/2012 8:51 PM BST
on bmj.com
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Posts: 3059
First: 27/3/2012 Last: 13/6/2013 |
There is a small increased risk of bladder cancer with the use of pioglitazone; epidemiological data suggest a relative risk of around 1.2 (ranging from 1.15 to 1.33 for ever use across studies). The benefit-risk balance remains positive in a limited population of type 2 diabetics. Prescribers are advised to carefully select patients based on individual patient’s risk factors and to periodically review the efficacy of the patient’s treatment in order to optimise the benefit-risk margin at the individual patient level by ensuring that only patients who are deriving sufficient benefit continue to take pioglitazone. |
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 21/6/2012 10:35 PM BST
on bmj.com
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Posts: 627
First: 13/4/2011 Last: 18/6/2013 |
Dear Colleagues: The saga of Pioglitazone has many similarities with the Rosiglitazone saga. The major ones are related to the later than usual clarifications of their serious side-effects, because of interest conflicted investigators, and drug-sponsored trials. Now it is clear: new onset heart failure, not to mention the double increase in bone fractures, namely in women, and the significant increase in bladder cancer after the cumulative use for only 2 years. Is this a great drug to use in diabetes just in name of reducing a bit further the Surrogate end-point for diabetic complications of HBA1C?. Is it great to use a drug that increases heavily body weight in diabetics? Just for the records, Pioglitazone is not for sale anymore in France.
All Best, Joey
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 22/6/2012 9:02 AM BST
on bmj.com
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Posts: 1336
First: 13/4/2010 Last: 16/6/2013 |
Hi Joey - as a busy family doctor dealing with a lot of diabetes I think the glitazones and gliptins are some of the most over-rated drugs I have come across. In my practice we have two doctors with a special interest in diabetes and two qualified diabetic nurses. We run diabetic clinics and see all our patients at least twice a year. I have surveyed all of our patients taking glitazones or gliptins and, based on the NICE criteria for effective treatment (fall of HbA1C of />0.5% in old measure), only one third of these patients have shown an effective response. Have these drugs actually had a significant impact on mortality and morbidity? I hope you can tell me and if the answer is "no" then why do we keep using them? |
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 22/6/2012 2:19 PM BST
on bmj.com
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Posts: 627
First: 13/4/2011 Last: 18/6/2013 |
Hello skyesteve: Thanks for your interesting and challenging question. I have indeed a short space to answer that now. First, the diabetes scientific world is becoming progressively divided among the diabetologists, and clinicians that believe and have an almost religious fervour in strict glucose control, and low HBA1C levels (Preferentially below 7 to 7.5%) for most diabetics. They are getting to be known, as glucose-centered (Glucocentric) diabetologists. They usually agree with polypharmacy of anti-diabetic drugs for the treatment and even prevention of type 2 diabetes. The drug industry, not only agree with this concept, they put a lot of money to disseminate this concept around the world; this attitude of polypharmacy of newer and non-evidence based anti-diabetic drugs for prevention and treatment of diabetes are leaded by the American Diabetes Association, the European Association for the Study of Diabetes, and the International Diabetes Federation, all of them having a tremendous financial support from the drugs&device industries, so, lacking the necessary and appropriate scientific independence. Of course, they issue a lot of professional guidelines regarding diabetes care. This paradigm of glucose control in the center stage of diabetes care for the prevention and treatment of macro and microvascular complications are not supported by all recent large clinical trials and good level Meta-Analysis. The belief of glucose as a major macro or microvascular toxin target came from extrapolations of observational studies, and from Surrogates of diabetic complications, such as microalbuminuria (which is almost reaching the status of a disease in its own); but as I told you, this glucocentric paradigm is defended with almost religious fervour by some diabetologists, and heavily supported by the drug industry. Now the PHARMA seems to be investing in the even larger market of the pre-diabetics, always with expensive new drugs and with the speech that these new drugs will better preserve pancreatic Beta-Cell function. Myself, and others diabetologists and clinicians that do research and take care of patients, do not believe that the best normalization of glucose or HBA1C levels should take the center stage of diabetes treatment. There are other more important clinical issues to be dealt with in type 2 diabetes care. I belong to this latter group of clinicians. That´s enough for now. I will talk about the best (and poor) available evidence of Pioglitazone effects on diabetic outcomes in a next post (the very much "painted" results of the PROactive study). Sorry for the long post. All Best, Joey
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 26/6/2012 3:11 PM BST
on bmj.com
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Posts: 627
First: 13/4/2011 Last: 18/6/2013 |
Hello skyesteve: This is just a BMJ warm-up for those enthusiastics of Pioglitazone "More marketing than science" Fiona Godlee, editor, BMJ BMJ 2012;344:e4269 "One uncertainty at least seems now to be resolved—the link between bladder cancer and pioglitazone. The study by Laurent Azoulay and colleagues clearly confirms an increased risk (doi:10.1136/bmj.e3645), which the linked editorial says could have been predicted earlier(doi:10.1136/bmj.e3500). Post-marketing studies found a link, but other clues were not picked up or acted on." I did not forget to mention to you about the PROactive study. Just very much busy now. All Best, Joey
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 27/6/2012 6:43 PM BST
on bmj.com
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Posts: 312
First: 2/6/2012 Last: 10/5/2013 |
among recent publication shows pioglitazone increase cancer risk and agrrevate heart failure.we should use it cautiosly but meta analysis is needed for further confirmation. |
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Re: Who Still Uses Pioglitazone in Type 2 Diabetes?
posted at 2/7/2012 1:00 AM BST
on bmj.com
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Posts: 627
First: 13/4/2011 Last: 18/6/2013 |
Hello skyesteve: Sorry for the delayed response to you. I was quite busy these days and had to get back to read about what is considered to be the best available evidence for a so-called anti-diabetic drug that I do not use for quite a while because of safety and effectiveness reasons: Pioglitazone. There are some diabetologists, and as you mentioned GPs, that still use this drug. In my opinion this is a quite dangerous anti-hyperglycaemic drug. The best available evidence for hard cardiovascular outcomes benefits is the PROactive study. In short words this study was negative for the composite primary outcome that tested the hypothesis of cardiovascular benefits and safety beyond glucose lowering. The signals of significant increased incidences for bladder cancer and for heart failure were already there, but they were manipulated by the authors of the article. Patients that developed bladder cancer in the pioglitazone were taken out from the analysis. Hospitalizations because of heart failure were twice more frequent in the pioglitazone, but there were no deaths caused by heart failure during the short-term follow-up. The PROactive study was published in the prestigious journal Lancet. It was positive only for the (also painted) secondary cardiovascular outcomes that could be at best hypothesis generating but were presented in several medical meetings (and also in the Lancet publication) as hard cardiovascular outcomes benefits of Pioglitazone. The weight gain of this drug is not inocent, it is indeed related to new-onset and worsening heart failure. The observational post-marketing studies, were also very manipulated to indulge physicians and patients that this is a safe and effective, and a cardiovascular risk reduction anti-diabetic drug. The PROactive study was heavily and correctly criticized because of those results manipulations, but you know what the power of pharmaceutical companies can do about hearts and minds of media and the so-called opinion makers physicians. In my patients, I do not use it for quite a few years, just because I do not believe that this is a safe or effective anti-diabetic drug. Oh yes, pioglitazone reduces blood glucose and HBA1C levels, but at what price: Universal weight gain, frequent new-onset and worsening heart failures, significantly increased risk for cancer, and bone fractures! By the way, blood glucose levels and HBA1C are just Surrogates for diabetic complications. Are they really good targets for treatment? All Best, Joey |
Forums » Open clinical » Diabetes » Who Still Uses Pioglitazone in Type 2 Diabetes?
