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Pioglitazone accord, inn pioglitazone hydrochloride

SUMMARY OF PRODUCT CHARACTERISTICS
NAME OF THE MEDICINAL PRODUCT

Pioglitazone Accord 15 mg tablets
2.
QUALITATIVE AND QUANTITATIVE COMPOSITION

Each tablet contains 15 mg of pioglitazone (as hydrochloride).
Excipient(s):
Each tablet contains 37.24 mg of lactose monohydrate (see section 4.4).
For a full list of excipients, see section 6.1.
3.
PHARMACEUTICAL FORM

Tablet.
The tablets are white to off white, round, biconvex, uncoated tablets debossed with ‘P' on one side and
‘15' on other side.
4.
CLINICAL PARTICULARS
Therapeutic indications
Pioglitazone is indicated as second or third line treatment of type 2 diabetes mellitus as described below: : as monotherapy
-
in adult patients (particularly overweight patients) inadequately controlled by diet and exercise for whom metformin is inappropriate because of contraindications or intolerance
After initiation of therapy with pioglitazone, patients should be reviewed after 3 to 6 months to assess
adequacy of response to treatment (e.g. reduction in HbA1c). In patients who fail to show an adequate
response, pioglitazone should be discontinued. In light of potential risks with prolonged therapy,
prescribers should confirm at subsequent routine reviews that the benefit of pioglitazone is maintained
(see section 4.4).
4.2
Posology and method of administration
Posology Pioglitazone treatment may be initiated at 15 mg or 30 mg once daily. The dose may be increased in increments up to 45 mg once daily. Special population Elderly No dose adjustment is necessary for elderly patients (see section 5.2). Physicians should start treatment with the lowest available dose and increase the dose gradually, particularly when pioglitazone is used in combination with insulin (see section 4.4 Fluid retention and cardiac failure). Renal impairment

No dose adjustment is necessary in patients with impaired renal function (creatinine
clearance > 4 ml/min) (see section 5.2). No information is available from dialysed patients therefore
pioglitazone should not be used in such patients.
Hepatic impairment

Pioglitazone should not be used in patients with hepatic impairment (see section 4.3 and 4.4).
Paediatric population
The safety and efficacy of Pioglitazone Accord in children and adolescents under 18 years of age have not
been established. No data are available.
Method of administration
Pioglitazone tablets are taken orally once daily with or without food. Tablets should be swallowed with a
glass of water.
4.3
Pioglitazone is contraindicated in patients with: - hypersensitivity to the active substance or to any of the excipients cardiac failure or history of cardiac failure (NYHA stages I to IV) hepatic impairment diabetic ketoacidosis current bladder cancer or a history of bladder cancer uninvestigated macroscopic haematuria Special warnings and precautions for use
Fluid retention and cardiac failure Pioglitazone can cause fluid retention, which may exacerbate or precipitate heart failure. When treating patients who have at least one risk factor for development of congestive heart failure (e.g. prior myocardial infarction or symptomatic coronary artery disease or the elderly), physicians should start with the lowest available dose and increase the dose gradually. Patients should be observed for signs and symptoms of heart failure, weight gain or oedema; particularly those with reduced cardiac reserve. There have been post-marketing cases of cardiac failure reported when pioglitazone was used in combination with insulin or in patients with a history of cardiac failure. Patients should be observed for signs and symptoms of heart failure, weight gain and oedema when pioglitazone is used in combination with insulin. Since insulin and pioglitazone are both associated with fluid retention, concomitant administration may increase the risk of oedema. Post marketing cases of peripheral oedema and cardiac failure have also been reported in patients with concomitant use of pioglitazone and nonsteroidal anti-inflammatory drugs, including selective COX-2 inhibitors. Pioglitazone should be discontinued if any deterioration in cardiac status occurs. A cardiovascular outcome study of pioglitazone has been performed in patients under 75 years with type 2 diabetes mellitus and pre-existing major macrovascular disease. Pioglitazone or placebo was added to existing antidiabetic and cardiovascular therapy for up to 3.5 years. This study showed an increase in reports of heart failure, however this did not lead to an increase in mortality in this study. Elderly Combination use with insulin should be considered with caution in the elderly because of increased risk of serious heart failure. In light of age- related risks (especially bladder cancer, fractures and heart failure), the balance of benefits and risks should be considered carefully both before and during treatment in the elderly. Bladder Cancer Cases of bladder cancer were reported more frequently in a meta-analysis of controlled clinical trials with pioglitazone (19 cases from 12506 patients, 0.15%) than in control groups (7 cases from 10212 patients, 0.07%) HR=2.64 (95% CI 1.11-6.31, P=0.029). After excluding patients in whom exposure to study drug was less than one year at the time of diagnosis of bladder cancer, there were 7 cases (0.06%) on pioglitazone and 2 cases (0.02%) in control groups. Available epidemiological data also suggest a small increased risk of bladder cancer in diabetic patients treated with pioglitazone in particular in patients treated for the longest durations and with the highest cumulative doses. A possible risk after short term treatment cannot be excluded. Risk factors for bladder cancer should be assessed before initiating pioglitazone treatment (risks include age, smoking history, exposure to some occupational or chemotherapy agents e.g. cyclophosphamide or prior radiation treatment in the pelvic region). Any macroscopic haematuria should be investigated before starting pioglitazone therapy. Patients should be advised to promptly seek the attention of their physician if macroscopic haematuria or other symptoms such as dysuria or urinary urgency develop during treatment. Monitoring of liver function There have been rare reports of hepatocellular dysfunction during post-marketing experience (see section 4.8). It is recommended, therefore, that patients treated with pioglitazone undergo periodic monitoring of liver enzymes. Liver enzymes should be checked prior to the initiation of therapy with pioglitazone in all patients. Therapy with pioglitazone should not be initiated in patients with increased baseline liver enzyme levels (ALT > 2.5 X upper limit of normal) or with any other evidence of liver disease. Following initiation of therapy with pioglitazone, it is recommended that liver enzymes be monitored periodically based on clinical judgement. If ALT levels are increased to 3 X upper limit of normal during pioglitazone therapy, liver enzyme levels should be reassessed as soon as possible. If ALT levels remain > 3 X the upper limit of normal, therapy should be discontinued. If any patient develops symptoms suggesting hepatic dysfunction, which may include unexplained nausea, vomiting, abdominal pain, fatigue, anorexia and/or dark urine, liver enzymes should be checked. The decision whether to continue the patient on therapy with pioglitazone should be guided by clinical judgement pending laboratory evaluations. If jaundice is observed, the medicinal product should be discontinued. Weight gain In clinical trials with pioglitazone there was evidence of dose related weight gain, which may be due to fat accumulation and in some cases associated with fluid retention. In some cases weight increase may be a symptom of cardiac failure, therefore weight should be closely monitored. Part of the treatment of diabetes is dietary control. Patients should be advised to adhere strictly to a calorie-controlled diet. Haematology There was a small reduction in mean haemoglobin (4% relative reduction) and haematocrit (4.1% relative reduction) during therapy with pioglitazone, consistent with haemodilution. Similar changes were seen in metformin (haemoglobin 3-4% and haematocrit 3.6–4.1% relative reductions) and to a lesser extent sulphonylurea and insulin (haemoglobin 1–2% and haematocrit 1–3.2% relative reductions) treated patients in comparative controlled trials with pioglitazone. Hypoglycaemia As a consequence of increased insulin sensitivity, patients receiving pioglitazone in dual or triple oral therapy with a sulphonylurea or in dual therapy with insulin may be at risk for dose-related hypoglycaemia, and a reduction in the dose of the sulphonylurea or insulin may be necessary. Eye disorders Post-marketing reports of new-onset or worsening diabetic macular oedema with decreased visual acuity have been reported with thiazolidinediones, including pioglitazone. Many of these patients reported concurrent peripheral oedema. It is unclear whether or not there is a direct association between pioglitazone and macular oedema but prescribers should be alert to the possibility of macular oedema if patients report disturbances in visual acuity; an appropriate ophthalmological referral should be considered. Others An increased incidence in bone fractures in women was seen in a pooled analysis of adverse reactions of bone fracture from randomised, controlled, double blind clinical trials in over 8100 pioglitazone and 7400 comparator treated patients, on treatment for up to 3.5 years. Fractures were observed in 2.6% of women taking pioglitazone compared to 1.7% of women treated with a comparator. No increase in fracture rates was observed in men treated with pioglitazone (1.3%) versus comparator (1.5%). The fracture incidence calculated was 1.9 fractures per 100 patient years in women treated with pioglitazone and 1.1 fractures per 100 patient years in women treated with a comparator. The observed excess risk of fractures for women in this dataset on pioglitazone is therefore 0.8 fractures per 100 patient years of use. In the 3.5 year cardiovascular risk PROactive study, 44/870 (5.1%; 1.0 fractures per 100 patient years) of pioglitazone-treated female patients experienced fractures compared to 23/905 (2.5%; 0.5 fractures per 100 patient years) of female patients treated with comparator. No increase in fracture rates was observed in men treated with pioglitazone (1.7%) versus comparator (2.1%). Some epidemiological studies have suggested a similarly increased risk of fracture in both men and women. The risk of fractures should be considered in the long term care of patients treated with pioglitazone. As a consequence of enhancing insulin action, pioglitazone treatment in patients with polycystic ovarian syndrome may result in resumption of ovulation. These patients may be at risk of pregnancy. Patients should be aware of the risk of pregnancy and if a patient wishes to become pregnant or if pregnancy occurs, the treatment should be discontinued (see section 4.6). Pioglitazone should be used with caution during concomitant administration of cytochrome P450 2C8 inhibitors (e.g. gemfibrozil) or inducers (e.g. rifampicin). Glycaemic control should be monitored closely. Pioglitazone dose adjustment within the recommended posology or changes in diabetic treatment should
be considered (see section 4.5).
Pioglitazone Accord tablets contain lactose monohydrate and therefore should not be administered to
patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-
galactose malabsorption.
4.5
Interaction with other medicinal products and other forms of interaction

Interaction studies have shown that pioglitazone has no relevant effect on either the pharmacokinetics or
pharmacodynamics of digoxin, warfarin, phenprocoumon and metformin. Co-administration of
pioglitazone with sulphonylureas does not appear to affect the pharmacokinetics of the sulphonylurea.
Studies in man suggest no induction of the main inducible cytochrome P450, 1A, 2C8/9 and 3A4. In vitro
studies have shown no inhibition of any subtype of cytochrome P450. Interactions with substances
metabolised by these enzymes, e.g. oral contraceptives, cyclosporin, calcium channel blockers, and
HMGCoA reductase inhibitors are not to be expected.
Co-administration of pioglitazone with gemfibrozil (an inhibitor of cytochrome P450 2C8) is reported to
result in a 3-fold increase in AUC of pioglitazone. Since there is a potential for an increase in dose-related
adverse events, a decrease in the dose of pioglitazone may be needed when gemfibrozil is concomitantly
administered. Close monitoring of glycaemic control should be considered (see section 4.4). Co-
administration of pioglitazone with rifampicin (an inducer of cytochrome P450 2C8) is reported to result
in a 54% decrease in AUC of pioglitazone. The pioglitazone dose may need to be increased when
rifampicin is concomitantly administered. Close monitoring of glycaemic control should be considered
(see section 4.4).
4.6
Fertility, pregnancy and lactation

Pregnancy
There are no adequate human data to determine the safety of pioglitazone during pregnancy. Foetal
growth restriction was apparent in animal studies with pioglitazone. This was attributable to the action of
pioglitazone in diminishing the maternal hyperinsulinaemia and increased insulin resistance that occurs
during pregnancy thereby reducing the availability of metabolic substrates for foetal growth. The
relevance of such a mechanism in humans is unclear and pioglitazone should not be used in pregnancy.
Breast-feeding
Pioglitazone has been shown to be present in the milk of lactating rats. It is not known whether
pioglitazone is secreted in human milk. Therefore, pioglitazone should not be administered to breast-
feeding women.
Fertility
In animal fertility studies there was no effect on copulation, impregnation or fertility index.
4.7
Effects on ability to drive and use machines
Pioglitazone Accord has no or negligible effect on the ability to drive and use machines. However patients who experience visual disturbance should be cautious when driving or using machines. Undesirable effects
Adverse reactions reported in excess (> 0.5%) of placebo and as more than an isolated case in patients receiving pioglitazone in double-blind studies are listed below as MedDRA preferred term by system organ class and absolute frequency. Frequencies are defined as: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to< 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing incidence and seriousness. Adverse reaction
Frequency of adverse reactions of pioglitazone by treatment regimen
Combination
with sulpho-
with insulin
metformin
metformin
Infections and infestations
upper respiratory tract infection
bronchitis
Blood and lymphatic
system disorders
anaemia
Immune System
Disorders
Hypersensitivity and
allergic reactions1
Metabolism and nutrition
disorders
hypo-glycaemia
appetite increased Nervous system disorders
Eye disorders
visual disturbance2 Ear and labyrinth
disorders
vertigo
Cardiac disorders
Neoplasms benign,
malignant and unspecified
(including cysts and

Respiratory, thoracic and
mediastinal disorders
dyspnoea
Gastrointestinal disorders
Skin and subcutaneous
tissue disorders
sweating
Musculoskeletal and
connective tissue
disorders
fracture bone5
Renal and urinary
disorders
haematuria
Reproductive system and
breast disorders
erectile dysfunction
General disorders and
administration site
conditions
oedema
weight increased6 blood creatine phospho- kinase increased increased lactic dehydro- 1 Postmarketing reports of hypersensitivity reactions in patients treated with pioglitazone have been reported. These reactions include anaphylaxis, angioedema, and urticaria. 2 Visual disturbance has been reported mainly early in treatment and is related to changes in blood glucose due to temporary alteration in the turgidity and refractive index of the lens as seen with other hypoglycaemic treatments. 3 Oedema was reported in 6–9% of patients treated with pioglitazone over one year in controlled clinical trials. The oedema rates for comparator groups (sulphonylurea, metformin) were 2–5%. The reports of oedema were generally mild to moderate and usually did not require discontinuation of treatment. 4 In controlled clinical trials the incidence of reports of heart failure with pioglitazone treatment was the same as in placebo, metformin and sulphonylurea treatment groups, but was increased when used in combination therapy with insulin. In an outcome study of patients with pre-existing major macrovascular disease, the incidence of serious heart failure was 1.6% higher with pioglitazone than with placebo, when added to therapy that included insulin. However, this did not lead to an increase in mortality in this study.
In this study in patients receiving pioglitazone and insulin, a higher percentage of patients with heart
failure was observed in patients aged ≥65 years compared with those less than 65 years (9.7% compared
to 4.0%). In patients on insulin with no pioglitazone the incidence of heart failure was 8.2% in those
≥65 years compared to 4.0% in patients less than 65 years. Heart failure has been reported with marketing
use of pioglitazone, and more frequently when pioglitazone was used in combination with insulin or in
patients with a history of cardiac failure.
5 A pooled analysis was conducted of adverse reactions of bone fractures from randomised, comparator
controlled, double blind clinical trials in over 8100 patients in the pioglitazone-treated groups and 7400 in
the comparator-treated groups of up to 3.5 years duration. A higher rate of fractures was observed in
women taking pioglitazone (2.6%) versus comparator (1.7%). No increase in fracture rates was observed
in men treated with pioglitazone (1.3%) versus comparator (1.5%).
In the 3.5 year PROactive study, 44/870 (5.1%) of pioglitazone-treated female patients experienced
fractures compared to 23/905 (2.5%) of female patients treated with comparator. No increase in fracture
rates was observed in men treated with pioglitazone (1.7%) versus comparator (2.1%).
6 In active comparator controlled trials mean weight increase with pioglitazone given as monotherapy was
2–3 kg over one year. This is similar to that seen in a sulphonylurea active comparator group. In
combination trials pioglitazone added to metformin resulted in mean weight increase over one year of
1.5 kg and added to a sulphonylurea of 2.8 kg. In comparator groups addition of sulphonylurea to
metformin resulted in a mean weight gain of 1.3 kg and addition of metformin to a sulphonylurea a mean
weight loss of 1.0 kg.
7 In clinical trials with pioglitazone the incidence of elevations of ALT greater than three times the upper
limit of normal was equal to placebo but less than that seen in metformin or sulphonylurea comparator
groups. Mean levels of liver enzymes decreased with treatment with pioglitazone. Rare cases of elevated
liver enzymes and hepatocellular dysfunction have occurred in post-marketing experience. Although in
very rare cases fatal outcome has been reported, causal relationship has not been established.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows
continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are
asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.
4.9
Overdose

In clinical studies, patients have taken pioglitazone at higher than the recommended highest dose of
45 mg daily. The maximum reported dose of 120 mg/day for four days, then 180 mg/day for seven days
was not associated with any symptoms.
Hypoglycaemia may occur in combination with sulphonylureas or insulin. Symptomatic and general
supportive measures should be taken in case of overdose.
5.
PHARMACOLOGICAL PROPERTIES
Pharmacodynamic properties
Pharmacotherapeutic group: Drugs used in diabetes, blood glucose lowering drugs, excl. insulins; ATC code: A10BG03. Pioglitazone effects may be mediated by a reduction of insulin resistance. Pioglitazone appears to act via activation of specific nuclear receptors (peroxisome proliferator activated receptor gamma) leading to increased insulin sensitivity of liver, fat and skeletal muscle cells in animals. Treatment with pioglitazone has been shown to reduce hepatic glucose output and to increase peripheral glucose disposal in the case of insulin resistance. Fasting and postprandial glycaemic control is improved in patients with type 2 diabetes mellitus. The improved glycaemic control is associated with a reduction in both fasting and postprandial plasma insulin concentrations. A clinical trial of pioglitazone vs. gliclazide as monotherapy was extended to two years in order to assess time to treatment failure (defined as appearance of HbA1c ≥ 8.0% after the first six months of therapy). Kaplan-Meier analysis showed shorter time to treatment failure in patients treated with gliclazide, compared with pioglitazone. At two years, glycaemic control (defined as HbA1c < 8.0%) was sustained in 69% of patients treated with pioglitazone, compared with 50% of patients on gliclazide. In a two-year study of combination therapy comparing pioglitazone with gliclazide when added to metformin, glycaemic control measured as mean change from baseline in HbA1c was similar between treatment groups after one year. The rate of deterioration of HbA1c during the second year was less with pioglitazone than with gliclazide. In a placebo controlled trial, patients with inadequate glycaemic control despite a three month insulin optimisation period were randomised to pioglitazone or placebo for 12 months. Patients receiving pioglitazone had a mean reduction in HbA1c of 0.45% compared with those continuing on insulin alone, and a reduction of insulin dose in the pioglitazone treated group. HOMA analysis shows that pioglitazone improves beta cell function as well as increasing insulin sensitivity. Two-year clinical studies have shown maintenance of this effect. In one year clinical trials, pioglitazone consistently gave a statistically significant reduction in the albumin/creatinine ratio compared to baseline. The effect of pioglitazone (45 mg monotherapy vs. placebo) was studied in a small 18-week trial in type 2 diabetics. Pioglitazone was associated with significant weight gain. Visceral fat was significantly decreased, while there was an increase in extra-abdominal fat mass. Similar changes in body fat distribution on pioglitazone have been accompanied by an improvement in insulin sensitivity. In most clinical trials, reduced total plasma triglycerides and free fatty acids, and increased HDL-cholesterol levels were observed as compared to placebo, with small, but not clinically significant increases in LDL-cholesterol levels. In clinical trials of up to two years duration, pioglitazone reduced total plasma triglycerides and free fatty acids, and increased HDL cholesterol levels, compared with placebo, metformin or gliclazide. Pioglitazone did not cause statistically significant increases in LDL cholesterol levels compared with placebo, whilst reductions were observed with metformin and gliclazide. In a 20-week study, as well as reducing fasting triglycerides, pioglitazone reduced post prandial hypertriglyceridaemia through an effect on both absorbed and hepatically synthesised triglycerides. These effects were independent of pioglitazone's effects on glycaemia and were statistically significant different to glibenclamide. In PROactive, a cardiovascular outcome study, 5238 patients with type 2 diabetes mellitus and pre-existing major macrovascular disease were randomised to pioglitazone or placebo in addition to existing antidiabetic and cardiovascular therapy, for up to 3.5 years. The study population had an average age of 62 years; the average duration of diabetes was 9.5 years. Approximately one third of patients were receiving insulin in combination with metformin and/or a sulphonylurea. To be eligible patients had to have had one or more of the following: myocardial infarction, stroke, percutaneous cardiac intervention or coronary artery bypass graft, acute coronary syndrome, coronary artery disease, or peripheral arterial obstructive disease. Almost half of the patients had a previous myocardial infarction and approximately 20% had had a stroke. Approximately half of the study population had at least two of the cardiovascular history entry criteria. Almost all subjects (95%) were receiving cardiovascular medicinal products (beta blockers, ACE inhibitors, angiotensin II antagonists, calcium channel blockers, nitrates, diuretics, aspirin,
statins, fibrates).
Although the study failed regarding its primary endpoint, which was a composite of all-cause mortality,
non-fatal myocardial infarction, stroke, acute coronary syndrome, major leg amputation, coronary
revascularisation and leg revascularisation, the results suggest that there are no long-term cardiovascular
concerns regarding use of pioglitazone. However, the incidences of oedema, weight gain and heart failure
were increased. No increase in mortality from heart failure was observed.
Paediatric population
The European Medicines Agency has waived the obligation to submit the results of studies with
Pioglitazone in all subsets of the paediatric population in Type 2 Diabetes Mellitus. See section 4.2 for
information on paediatric use.
5.2
Pharmacokinetic properties

Absorption
Following oral administration, pioglitazone is rapidly absorbed, and peak plasma concentrations of
unchanged pioglitazone are usually achieved 2 hours after administration. Proportional increases of the
plasma concentration were observed for doses from 2–60 mg. Steady state is achieved after
4–7 days of dosing. Repeated dosing does not result in accumulation of the compound or metabolites.
Absorption is not influenced by food intake. Absolute bioavailability is greater than 80%.
Distribution
The estimated volume of distribution in humans is 0.25 l/kg.
Pioglitazone and all active metabolites are extensively bound to plasma protein (> 99%).
Biotransformation
Pioglitazone undergoes extensive hepatic metabolism by hydroxylation of aliphatic methylene groups.
This is predominantly via cytochrome P450 2C8 although other isoforms may be involved to a lesser
degree. Three of the six identified metabolites are active (M-II, M-III, and M-IV). When activity,
concentrations and protein binding are taken into account, pioglitazone and metabolite M-III contribute
equally to efficacy. On this basis M-IV contribution to efficacy is approximately three-fold that of
pioglitazone, whilst the relative efficacy of M-II is minimal.
In vitro studies have shown no evidence that pioglitazone inhibits any subtype of cytochrome P450. There
is no induction of the main inducible P450 isoenzymes 1A, 2C8/9, and 3A4 in man.
Interaction studies have shown that pioglitazone has no relevant effect on either the pharmacokinetics or
pharmacodynamics of digoxin, warfarin, phenprocoumon and metformin. Concomitant administration of
pioglitazone with gemfibrozil (an inhibitor of cytochrome P450 2C8) or with rifampicin (an inducer of
cytochrome P450 2C8) is reported to increase or decrease, respectively, the plasma concentration of
pioglitazone (see section 4.5).

Elimination
Following oral administration of radiolabelled pioglitazone to man, recovered label was mainly in faeces
(55%) and a lesser amount in urine (45%). In animals, only a small amount of unchanged pioglitazone can
be detected in either urine or faeces. The mean plasma elimination half-life of unchanged pioglitazone in
man is 5 to 6 hours and for its total active metabolites 16 to 23 hours.
Elderly
Steady state pharmacokinetics are similar in patients age 65 and over and young subjects.
Patients with renal impairment
In patients with renal impairment, plasma concentrations of pioglitazone and its metabolites are lower
than those seen in subjects with normal renal function, but oral clearance of parent substance is similar.
Thus free (unbound) pioglitazone concentration is unchanged.
Patients with hepatic impairment
Total plasma concentration of pioglitazone is unchanged, but with an increased volume of distribution.
Intrinsic clearance is therefore reduced, coupled with a higher unbound fraction of pioglitazone.
5.3
Preclinical safety data

In toxicology studies, plasma volume expansion with haemodilution, anaemia, and reversible eccentric
cardiac hypertrophy was consistently apparent after repeated dosing of mice, rats, dogs, and monkeys. In
addition, increased fatty deposition and infiltration were observed. These findings were observed across
species at plasma concentrations  4 times the clinical exposure. Foetal growth restriction was apparent in
animal studies with pioglitazone. This was attributable to the action of pioglitazone in diminishing the
maternal hyperinsulinaemia and increased insulin resistance that occurs during pregnancy thereby
reducing the availability of metabolic substrates for foetal growth.
Pioglitazone was devoid of genotoxic potential in a comprehensive battery of in vivo and in vitro
genotoxicity assays. An increased incidence of hyperplasia (males and females) and tumours (males) of
the urinary bladder epithelium was apparent in rats treated with pioglitazone for up to 2 years.
The formation and presence of urinary calculi with subsequent irritation and hyperplasia was postulated
as the mechanistic basis for the observed tumourigenic response in the male rat. A 24-month mechanistic
study in male rats demonstrated that administration of pioglitazone resulted in an increased incidence of
hyperplastic changes in the bladder. Dietary acidification significantly decreased but did not abolish the
incidence of tumours. The presence of microcrystals exacerbated the hyperplastic response but was not
considered to be the primary cause of hyperplastic changes. The relevance to humans of the tumourigenic
findings in the male rat cannot be excluded.
There was no tumorigenic response in mice of either sex. Hyperplasia of the urinary bladder was not seen
in dogs or monkeys treated with pioglitazone for up to 12 months.
In an animal model of familial adenomatous polyposis (FAP), treatment with two other thiazolidinediones
increased tumour multiplicity in the colon. The relevance of this finding is unknown.
Environmental Risk Assessment: no environmental impact is anticipated from the clinical use of
pioglitazone.

6.

PHARMACEUTICAL PARTICULARS
List of excipients
Carmellose calcium
Hydroxypropyl cellulose
Lactose monohydrate
Magnesium stearate
6.2

Not applicable
6.3
Shelf life

3 years

6.4

Special precautions for storage

This medicinal product does not require any special storage conditions
6.5
Nature and contents of container

Aluminium/aluminium blisters, packs of 14, 28, 30, 50, 56, 84, 90, 98, 112 and 196 tablets.
Not all pack sizes may be marketed.
6.6
Special precautions for disposal

No special requirements.
7.
MARKETING AUTHORISATION HOLDER

Accord Healthcare Limited
Sage House, 319 Pinner Road, North Harrow, HA1 4 HF, Middlesex
United Kingdom
8.
MARKETING AUTHORISATION NUMBER(S)

EU/1/11/722/001-010 (14/28/30/50/56/84/90/98/112/196 tablets in alu/alu blister)
9.
DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

21-March-2012
10.
DATE OF REVISION OF THE TEXT
12/12/2013 Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu

Source: http://www.accord-healthcare.eu/files/files/homepage-files/Pioglitazone%2015%20mg%20SPC%2012.12.2013.pdf

schlafapnoe-selbsthilfe.ch

[302] Das körperliche Altern des Schlafes Oder: Das Schlafmuster verändert sich im Alter Dr. Paul-André Despland, CHUV Lausanne Das Bedürfnis, zu schlafen und sich auszuruhen, ist eine Notwendigkeit für den Menschen. Der Schlaf und das Ruhen setzen eine Erschlaffung der Muskeln voraus. Das Ruhen wird zum Schlaf, wenn die Person keine oder fast keine Wechselbeziehung zu ihrer Umwelt mehr hat. Der Schlaf umfasst zwei aufeinander folgende sich deutlich unterscheidende Phasen: Den langsamen und ruhigen Schlaf und den paradoxen Schlaf mit Traumphasen. Der langsame Schlaf und der paradoxe Schlaf wechseln sich stadienweise ab. Ein ruhiger, langsamer, leichter und tiefer Schlafzyklus bildet zusammen mit einem 1. paradoxen Schlafstadium eine Schlafperiode von 90 Minuten. Diese Schlafperiodewiederholt sich anschliessend 4 bis 5 Mal pro Nacht. Braucht man mit zunehmendem Alter weniger Schlaf? Die Hypothese, dass ein alter Mensch aufgrund einer verminderten körperlichen und geistigen Aktivität weniger Schlaf braucht, ist eine falsche Vorstellung. Es ist nicht der Schlafbedarf, der mit dem Alter abnimmt, sondern die Fähigkeit zu schlafen. Die meisten Menschen benötigen 5 bis 7 Stunden Schlaf, auch im Alter von über 60 und über 80 Jahren. Das physiologische Altern des Schlafes Die Schlaflabors, die sich mit den Schlafstörungen des alten Menschen befassen, gelangen einhellig zu den nachstehenden Feststellungen und Schlussfolgerungen:

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Grapefruit juice and St John's Wortare just the tip of the icebergHow can we prevent damaging interactions in this era of long-term oral cancer therapies? ➜ Anna Wagstaff Certain foods, prescription drugs and complementary remedies interact with cancer therapies, altering the effective dose and putting patients at risk. Yet there is scant clinical evidence on which