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.
Continue1, 2.

EXCEPT:

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

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

Patients having Surgery for Bladder Cancer

Pioglitazone containing medications are contraindicated in previous or active bladder cancer (see Further Information).

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 prescribed1, 2.

Post-operative Advice

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

For combination product containing metformin – follow advice on restarting in Metformin monograph.


  Interaction(s) with Common Anaesthetic Agents


None2, 3, 4, 5.


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


None for pioglitazone alone2, 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 metformin– 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 (although VRIII may be necessary if emergency surgery or in people with poorly controlled diabetes (HbA1c >69mmol/mol))1. Patients with type 2 diabetes who are expected to miss more than one meal should have VRIII if they develop hyperglycaemia (capillary blood glucose (CBG) >12mmol/L)1.

Bladder Cancer

Pioglitazone is contraindicated in patients with active or previous bladder cancer and should be used with caution in patients with risk factors for bladder cancer as the European Medicines Agency have advised that there is a small increased risk of bladder cancer in patients treated with pioglitazone2, 3, 5.

 

  References



  1. Centre for Perioperative Care. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery (March 2021). Available at: https://cpoc.org.uk/guidelines-resources/guidelines [Accessed on 8th March 2021]
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 27th February 2021]
  3. Summary of Product Characteristics – Actos® (pioglitazone) Tablets. Takeda UK Ltd. Accessed via www.medicines.org.uk 27/02/2021 [date of revision of the text June 2019]
  4. Pioglitazone Hydrochloride. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. Electronic version. Truven Health Analytics, Greenwood Village, Colorado, USA. http://www.micromedexsolutions.com [Accessed 1st March 2021]
  5.  Summary of Product Characteristics – Competact® (pioglitazone + metformin) 15mg/850mg film-coated Tablets. Takeda UK Ltd. Accessed via www.medicines.org.uk 27/02/2021 [date of revision of the text October 2018]