Pioglitazone Therapy for Secondary Stroke Prevention

Evidence for Stroke Prevention

The American Heart Association recommends pioglitazone for patients with type 2 diabetes and prior stroke, as it reduces recurrent stroke risk by 47% (HR 0.53, 95% CI 0.34-0.85) 1, 2
The American Diabetes Association notes that pioglitazone demonstrates a 28% relative risk reduction in the composite of stroke, MI, or vascular death (HR 0.72, 95% CI 0.53-1.00) in patients with type 2 diabetes and prior stroke 1, 2
The European Association for the Study of Diabetes recommends pioglitazone for patients with recent stroke/TIA and insulin resistance, as it reduces stroke or MI by 24% (9.0% vs 11.8%, HR 0.76, 95% CI 0.62-0.93) over 4.8 years 3
The American College of Cardiology notes that pioglitazone reduces acute coronary syndrome by 29% and MI by 38% in patients with recent stroke/TIA and insulin resistance 4, 5

The American Heart Association states that any history of heart failure (NYHA Class I-IV) is an absolute contraindication for pioglitazone therapy 6
The European Society of Cardiology notes that pioglitazone causes sodium retention, increasing plasma volume by 1.8 mL/kg, and has a hazard ratio for heart failure of 1.8 compared to sulfonylureas 5, 6

The American Diabetes Association recommends metformin as an initial agent for patients with type 2 diabetes, as it is weight-neutral and does not cause fluid retention 6
The European Heart Journal suggests SGLT-2 inhibitors as a second-line treatment, as they decrease both cardiovascular events and heart failure hospitalization 7, 6
The American College of Cardiology notes that GLP-1 receptor agonists may decrease cardiovascular events 8