Does pioglitazone reduce the rates of stroke and myocardial infarction after ischemic stroke or TIA in select patients?

Presenter: Angela Aziz Donnelly, MD

Link to PowerPoint Presentation:  Journal Club Apr 2016

Clinical Question:

Does pioglitazone reduce the rates of stroke and myocardial infarction after ischemic stroke or TIA in select patients?

Journal Club Article:

Kernan WN et al.  Pioglitazone After Ischemic Stroke or Transient Ischemic Attack.  N Engl J Med, 2016 Apr 7;374(14):1321-31.  PDF attached: nejmoa1506930

Methodology:

In this multicenter, double-blind trial, 3876 patients were randomly assigned who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction.

Study Conclusions:

The risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo.  Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture.

  • Strict inclusion/exclusion criteria – e.g. no diabetes, no heart failure
  • Majority of population was white, male
  • Used HOMA-IR for measuring insulin resistance – how would we do this in clinical practice?
  • No comparison to lifestyle modifications
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