Pioglitazone interactions

Food & lifestyle

• alcohol

  Moderate

  Others

  Alcohol may cause hypoglycemia or hyperglycemia in patients with diabetes. Hypoglycemia most frequently occurs during acute consumption of alcohol. Even modest amounts can lower blood sugar significantly, especially when the alcohol is ingested on an empty stomach or following exercise. The mechanism involves inhibition of both gluconeogenesis as well as the counter-regulatory response to hypoglycemia. Episodes of hypoglycemia may last for 8 to 12 hours after ethanol ingestion. By contrast, chronic alcohol abuse can cause impaired glucose tolerance and hyperglycemia. Moderate alcohol consumption generally does not affect blood glucose levels in patients with well controlled diabetes. A disulfiram-like reaction (e.g., flushing, headache, and nausea) to alcohol has been reported frequently with the use of chlorpropamide and very rarely with other sulfonylureas.

  What to do: Patients with diabetes should avoid consuming alcohol if their blood glucose is not well controlled, or if they have hypertriglyceridemia, neuropathy, or pancreatitis. Patients with well controlled diabetes should limit their alcohol intake to one drink daily for women and two drinks daily for men (1 drink = 5 oz wine, 12 oz beer, or 1.5 oz distilled spirits) in conjunction with their normal meal plan. Alcohol should not be consumed on an empty stomach or following exercise.

  10 sources

  1. Jerntorp P, Almer LO "Chlorpropamide-alcohol flushing in relation to macroangiopathy and peripheral neuropathy in non-insulin dependent diabetes." Acta Med Scand 656 (1981): 33-6
  2. Jerntorp P, Almer LO, Holin H, et al. "Plasma chlorpropamide: a critical factor in chlorpropamide-alcohol flush." Eur J Clin Pharmacol 24 (1983): 237-42
  3. Barnett AH, Spiliopoulos AJ, Pyke DA, et al. "Metabolic studies in chlorpropamide-alcohol flush positive and negative type 2 (non-insulin dependent) diabetic patients with and without retinopathy." Diabetologia 24 (1983): 213-5
  4. Hartling SG, Faber OK, Wegmann ML, Wahlin-Boll E, Melander A "Interaction of ethanol and glipizide in humans." Diabetes Care 10 (1987): 683-6
  5. "Product Information. Diabinese (chlorpropamide)." Pfizer U.S. Pharmaceuticals (2002):
  6. "Product Information. Glucotrol (glipizide)." Pfizer U.S. Pharmaceuticals (2002):
  7. "Product Information. Diabeta (glyburide)." Hoechst Marion-Roussel Inc, Kansas City, MO.
  8. Skillman TG, Feldman JM "The pharmacology of sulfonylureas." Am J Med 70 (1981): 361-72

  Show all 10 sourcesShow fewer sources

  9. "Position Statement: evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes related complications. American Diabetes Association." Diabetes Care 25(Suppl 1) (2002): S50-S60
  10. Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0

Conditions

Conditions in which Pioglitazone needs care, as documented in this source.

• Diabetes Mellitus, Type 1

  Major

  Thiazolidinediones exert their hypoglycemic effect only in the presence of insulin. Therefore, these agents should not be used in patients with type I diabetes or for the treatment of diabetic ketoacidosis.

  2 sources

  1. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  2. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Heart Failure

  Major

  The use of thiazolidinediones, alone or in combination with other antidiabetic agents, has been associated with fluid retention and new onset or exacerbation of heart failure. An increased risk of cardiovascular events (heart failure worsening; new or worsening edema; new or worsening dyspnea; increases in heart failure medication; myocardial infarction; angina; cardiovascular hospitalization and deaths) has been reported with rosiglitazone therapy in type II diabetic patients with New York Heart Association (NYHA) Class I or II congestive heart failure compared to placebo. Likewise, overnight hospitalization for CHF was observed in 9.9% of diabetic patients with NYHA Class II and III heart failure on pioglitazone compared to 4.7% of patients on glyburide. An increased incidence of cardiovascular adverse events including edema and cardiac failure has also been reported in patients receiving a thiazolidinedione in combination with insulin relative to insulin and placebo. Therapy with thiazolidinediones should be administered cautiously and initiated at the lowest recommended dosage in patients with congestive heart failure. Thiazolidinediones are contraindicated for the treatment of patients with NYHA Class III or IV cardiac status. Patients should be monitored for signs of worsening heart failure such as increased dyspnea, edema, and weight gain. Therapy should be discontinued if any deterioration in cardiac status occurs.

  2 sources

  1. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  2. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Anovulation

  Moderate

  In premenopausal, anovulatory patients with insulin resistance, treatment with thiazolidinediones may result in resumption of ovulation. Due to improved insulin sensitivity, pregnancy can occur if adequate contraception is not used.

  3 sources

  1. "Product Information. Rezulin (troglitazone)." Parke-Davis (2001):
  2. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  3. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Edema

  Moderate

  Thiazolidinediones can cause dose-related edema. Therapy with thiazolidinediones should be administered cautiously in patients at risk for congestive heart failure as well as those with fluid overload or other conditions that may be adversely affected by excess fluid such as hypertension. Patients should be monitored for signs and symptoms of heart failure such as dyspnea, swelling of legs or ankles, and weight gain.

  4 sources

  1. "Product Information. Rezulin (troglitazone)." Parke-Davis (2001):
  2. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  3. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):
  4. Thomas ML, Lloyd SJ "Pulmonary edema associated with rosiglitazone and troglitazone." Ann Pharmacother 35 (2001): 123-4

• Liver Diseases

  Moderate

  Initiation of rosiglitazone or pioglitazone therapy is not recommended in patients who exhibit clinical evidence of active liver disease or increased baseline serum transaminase levels (ALT exceeding 2.5 times upper limit of normal). Use of these agents is also not recommended in patients who have experienced jaundice during treatment with troglitazone. The use of troglitazone, another agent in the thiazolidinedione class, has been associated with clinically significant elevations in liver enzymes, reversible jaundice, and idiosyncratic hepatocellular injury including rare cases of liver failure, liver transplants, and death. Injury has occurred after both short- and long-term treatment. While these effects have not been associated with other thiazolidinediones in clinical trials, concerns exist because of their structural similarities. In addition, isolated cases of hepatitis and hepatic enzyme elevations to 3 or more times the upper limit of normal have been reported with both rosiglitazone and pioglitazone during postmarketing use. Rarely, these events have involved hepatic failure with and without fatal outcome, although causality has not been established. Until more safety data are available, patients who are prescribed thiazolidinedione therapy should have serum transaminase levels checked at baseline and periodically thereafter as clinically necessary. Mild to moderate elevations (ALT less than or equal to 2.5 times ULN) require cautious use with more frequent monitoring to determine if the elevations resolve or worsen. Patients who develop potential symptoms of hepatic injury such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, and dark urine should have liver enzymes checked. Therapy should be withdrawn if ALT is elevated and persists above 3 times ULN or if jaundice develops.

  11 sources

  1. Watkins PB, Whitcomb RW "Hepatic dysfunction associated with troglitazone." N Engl J Med 338 (1998): 916-7
  2. Gitlin N, Julie NL, Spurr CL, Lim KN, Juarbe HM "Two cases of severe clinical and histologic hepatotoxicity associated with troglitazone." Ann Intern Med 129 (1998): 36-8
  3. Neuschwander-Tetre BA, Isley WL, Oki JC, et al. "Troglitazone-induced hepatic failure leading to liver transplantation: a case report." Ann Intern Med 129 (1998): 38-41
  4. NeuschwanderTetri BA, Isley WL, Oki JC, Ramrakhiani S, Quiason SG, Phillips NJ, Brunt EM "Troglitazone-induced hepatic failure leading to liver transplantation - A case report." Ann Intern Med 129 (1998): 38-41
  5. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  6. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):
  7. Forman LM, Simmons DA, Diamond RH "Hepatic failure in a patient taking rosiglitazone." Ann Intern Med 132 (2000): 118-21
  8. Prendergast KA, Berg CL, Wisniewski R "Troglitazone-associated hepatotoxicity treated successfully with steroids." Ann Intern Med 133 (2000): 751

  Show all 11 sourcesShow fewer sources

  9. Hachey DM, O'Neil MP, Force RW "Isolated elevation of alkaline level associated with rosiglitazone." Ann Intern Med 133 (2000): 752
  10. St. Peter JV, Neafus KL, Khan MA, Vessey JT, Lockheart SK "Factors associated with the risk of liver enzyme elevation in patients with type 2 diabetes treated with a thiazolidinedione." Pharmacotherapy 21 (2001): 183-88
  11. Maeda K "Hepatocellular injury in a patient receiving pioglitazone." Ann Intern Med 135 (2001): 306

• Macular Edema

  Moderate

  New onset or worsening diabetic macular edema with decreased visual acuity have been reported in postmarketing reports in some diabetic patients who were taking thiazolidinedione drugs. Some patients presented with blurred vision or decreased visual acuity, but some patients appear to have been diagnosed on routine ophthalmologic examination. Most patients had peripheral edema at the time macular edema was diagnosed. Some patients had improvement in their macular edema after discontinuation of their thiazolidinedione. Patients with diabetes should have regular eye exams by an ophthalmologist according to current standards of care. Additionally, any diabetic who reports any kind of visual symptom should be promptly referred to an ophthalmologist, regardless of the patient's underlying medications or other physical findings.

  3 sources

  1. "Product Information. Rezulin (troglitazone)." Parke-Davis (2001):
  2. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  3. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Urinary Bladder Neoplasms

  Moderate

  There are insufficient data to determine if pioglitazone has an effect on preexisting bladder tumors or if it can cause bladder cancer. However, the manufacturer does not recommend the use of pioglitazone in patients with active bladder cancer. In patients with history of bladder cancer the benefit of treatment versus the risk of cancer recurrence during treatment should be considered.

  1 source

  1. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Weight Gain

  Moderate

  Thiazolidinediones can cause dose-related weight gain, which may be undesirable in obese patients attempting to lose weight. The mechanism of weight gain is unclear but probably involves a combination of fluid retention and fat accumulation. In postmarketing experience with rosiglitazone, there have been reports of unusually rapid increases in weight, greater than those generally observed in clinical trials. Patients who experience such increases should be assessed for fluid retention and volume-related events such as excessive edema and congestive heart failure.

  2 sources

  1. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  2. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):

• Anemia

  Minor

  Thiazolidinediones can cause slight decreases in hemoglobin and hematocrit. In clinical studies, hemoglobin levels were reduced primarily within the first 4 to 12 weeks of therapy but remained relatively constant thereafter. These changes may be related to increased plasma volume and have rarely been associated with any significant hematologic clinical effects. Nevertheless, caution may be advisable when thiazolidinediones are prescribed to patients with certain anemias.

  2 sources

  1. "Product Information. Avandia (rosiglitazone)." SmithKline Beecham (2001):
  2. "Product Information. Actos (pioglitazone)." Takeda Pharmaceuticals America (2001):