Pioglitazone

  Issues for Surgery

Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if omitted.

Combination product containing metformin – risk of lactic acidosis if continued (see Interaction(s) with other Common Medicines used in the Perioperative Period and Further Information).

Potential for hypoglycaemia when taken concomitantly with other blood glucose lowering medicines and continued during nil by mouth (NBM) period.

  Advice in the Perioperative period

Elective and Emergency Surgery

Pioglitazone should be taken as normal the day prior to surgery (including combination products)¹.

Morning or Afternoon Surgery.
Continue^{1, 2}.

EXCEPT:

• Competact^® – contains metformin (see Metformin monograph).

Consideration should be given to prescribing the components of combination products as separate medicines perioperatively.

Perioperative Considerations

Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated (see Further Information) and omit pioglitazone during VRIII treatment¹.

Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel^® and 20% dextrose. Rapid acting insulin should also be prescribed^{1, 2}.

Post-operative Advice

If withheld due to use of VRIII, restart once eating and drinking normally¹.

  Interaction(s) with Common Anaesthetic Agents

None^{2, 3, 4, 5}.

  Interaction(s) with other Common Medicines used in the Perioperative Period

None for pioglitazone alone^{2, 3, 4}

Iodinated Contrast Agents

Caution with combination products containing metformin and concomitant use of iodinated contrast agents⁴ – see Metformin monograph.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

Caution with combination products containing metformin and concomitant use of NSAIDs⁵ – see Metformin monograph.

  Further Information

Lactic Acidosis

Risk of lactic acidosis with combination products containing metformin⁵ – see Metformin monograph.

VRIII

Patients with a planned short starvation period (no more than one missed meal in total) should be managed by modification of their usual diabetes medication, avoiding VRIII wherever possible. Patients expected to miss more than one meal should have VRIII¹.

  References

1. Joint British Diabetes Societies for Inpatient Care. Management of adults with diabetes undergoing surgery and elective procedures: improving standards (Revised March 2016). Available at: www.diabetes.org.uk [Accessed 6th April 2019]
2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 6^th April 2019]
3. Summary of Product Characteristics – Actos^® (pioglitazone) Tablets. Takeda UK Ltd. Accessed via www.medicines.org.uk 06/04/2019 [date of revision of the text October 2018]
4. Pioglitazone. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 30^th March 2019]
5. Summary of Product Characteristics – Competact^® (pioglitazone + metformin) 15mg/850mg film-coated Tablets. Takeda UK Ltd. Accessed via www.medicines.org.uk 06/04/2019 [date of revision of the text October 2018)