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