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Actos

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Actos

Side Effects
Interactions

SIDE EFFECTS

The following serious adverse reactions are discussed elsewhere in the labeling:

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Over 8500 patients with type 2 diabetes have been treated with ACTOS in randomized, double-blind, controlled clinical trials, including 2605 patients with type 2 diabetes and macrovascular disease treated with ACTOS in the PROactive clinical trial. In these trials, over 6000 patients have been treated with ACTOS for six months or longer, over 4500 patients have been treated with ACTOS for one year or longer, and over 3000 patients have been treated with ACTOS for at least two years.

In six pooled 16-to 26-week placebo-controlled monotherapy and 16-to 24-week add-on combination therapy trials, the incidence of withdrawals due to adverse events was 4.5% for patients treated with ACTOS and 5.8% for comparator-treated patients. The most common adverse events leading to withdrawal were related to inadequate glycemic control, although the incidence of these events was lower (1.5%) with ACTOS than with placebo (3.0%).

In the PROactive trial, the incidence of withdrawals due to adverse events was 9.0% for patients treated with ACTOS and 7.7% for placebo-treated patients. Congestive heart failure was the most common serious adverse event leading to withdrawal occurring in 1.3% of patients treated with ACTOS and 0.6% of patients treated with placebo.

Common Adverse Events: 16-to 26-Week Monotherapy Trials

A summary of the incidence and type of common adverse events reported in three pooled 16-to 26-week placebo-controlled monotherapy trials of ACTOS is provided in Table 1. Terms that are reported represent those that occurred at an incidence of > 5% and more commonly in patients treated with ACTOS than in patients who received placebo. None of these adverse events were related to ACTOS dose.

Table 1: Three Pooled 16-to 26-Week Placebo-Controlled Clinical Trials of ACTOS Monotherapy: Adverse Events Reported at an Incidence > 5% and More Commonly in Patients Treated with ACTOS than in Patients Treated with Placebo

  % of Patients
Placebo
N=259
ACTOS
N=606
Upper Respiratory Tract Infection 8.5 13.2
Headache 6.9 9.1
Sinusitis 4.6 6.3
Myalgia 2.7 5.4
Pharyngitis 0.8 5.1

Common Adverse Events: 16-to 24-Week Add-on Combination Therapy Trials

A summary of the overall incidence and types of common adverse events reported in trials of ACTOS add-on to sulfonylurea is provided in Table 2. Terms that are reported represent those that occurred at an incidence of > 5% and more commonly with the highest tested dose of ACTOS.

Table 2: 16-to 24-Week Clinical Trials of ACTOS Add-on to Sulfonylurea

  16-Week Placebo-Controlled Trial Adverse Events Reported in > 5% of Patients and More Commonly in Patients Treated with ACTOS 30 mg + Sulfonylurea than in Patients Treated with Placebo + Sulfonylurea
% of Patients
Placebo + Sulfonylurea
N=187
ACTOS 15 mg + Sulfonylurea
N=184
ACTOS 30 mg + Sulfonylurea
N=189
Edema 2.1 1.6 12.7
Headache 3.7 4.3 5.3
Flatulence 0.5 2.7 6.3
Weight Increased 0 2.7 5.3
  24-Week Non-Controlled Double-Blind Trial Adverse Events Reported in >5% of Patients and More Commonly in Patients Treated with ACTOS 45 mg + Sulfonylurea than in Patients Treated with ACTOS 30 mg + Sulfonylurea
% of Patients
ACTOS 30 mg + Sulfonylurea N=351 ACTOS 45 mg + Sulfonylurea N=351  
Hypoglycemia 13.4 15.7  
Edema 10.5 23.1  
Upper Respiratory Tract Infection 12.3 14.8  
Weight Increased 9.1 13.4  
Urinary Tract Infection 5.7 6.8  
Note: The preferred terms of edema peripheral, generalized edema, pitting edema and fluid retention were combined to form the aggregate term of “edema.”

A summary of the overall incidence and types of common adverse events reported in trials of ACTOS add-on to metformin is provided in Table 3. Terms that are reported represent those that occurred at an incidence of > 5% and more commonly with the highest tested dose of ACTOS.

Table 3: 16-to 24-Week Clinical Trials of ACTOS Add-on to Metformin

  16-Week Placebo-Controlled Trial Adverse Events Reported in >5% of Patients and More Commonly in Patients Treated with ACTOS + Metformin than in Patients Treated with Placebo + Metformin
% of Patients
Placebo + Metformin
N=160
ACTOS 30 mg + Metformin
N=168
Edema 2.5 6
Headache 1.9 6
  24-Week Non-Controlled Double-Blind Trial Adverse Events Reported in >5% of Patients and More Commonly in Patients Treated with ACTOS 45 mg + Metformin than in Patients Treated with ACTOS 30 mg + Metformin
% of Patients
ACTOS 30 mg + Metformin
N=411
ACTOS 45 mg + Metformin
N=416
Upper Respiratory Tract Infection 12.4 13.5
Edema 5.8 13.9
Headache 5.4 5.8
Weight Increased 2.9 6.7
Note: The preferred terms of edema peripheral, generalized edema, pitting edema and fluid retention were combined to form the aggregate term of “edema.”

Table 4 summarizes the incidence and types of common adverse events reported in trials of ACTOS add-on to insulin. Terms that are reported represent those that occurred at an incidence of > 5% and more commonly with the highest tested dose of ACTOS.

Table 4: 16-to 24-Week Clinical Trials of ACTOS Add-on to Insulin

  16-Week Placebo-Controlled Trial Adverse Events Reported in >5% of Patients and More Commonly in Patients Treated with ACTOS 30 mg + Insulin than in Patients Treated with Placebo + Insulin
% of Patients
Placebo + Insulin
N=187
ACTOS 15 mg + Insulin
N=191
ACTOS 30 mg + Insulin
N=188
Hypoglycemia 4.8 7.9 15.4
Edema 7 12.6 17.6
Upper Respiratory Tract Infection 9.6 8.4 14.9
Headache 3.2 3.1 6.9
Weight Increased 0.5 5.2 6.4
Back Pain 4.3 2.1 5.3
Dizziness 3.7 2.6 5.3
Flatulence 1.6 3.7 5.3
  24-Week Non-Controlled Double-Blind Trial Adverse Events Reported in >5% of Patients and More Commonly in Patients Treated with ACTOS 45 mg + Insulin than in Patients Treated with ACTOS 30 mg + Insulin
  % of Patients
  ACTOS 30 mg + Insulin
N=345
ACTOS 45 mg + Insulin
N=345
 
Hypoglycemia 43.5 47.8  
Edema 22 26.1  
Weight Increased 7.2 13.9  
Urinary Tract Infection 4.9 8.7  
Diarrhea 5.5 5.8  
Back Pain 3.8 6.4  
Blood Creatine Phosphokinase Increased 4.6 5.5  
Sinusitis 4.6 5.5  
Hypertension 4.1 5.5  
Note: The preferred terms of edema peripheral, generalized edema, pitting edema and fluid retention were combined to form the aggregate term of “edema.”

A summary of the overall incidence and types of common adverse events reported in the PROactive trial is provided in Table 5. Terms that are reported represent those that occurred at an incidence of > 5% and more commonly in patients treated with ACTOS than in patients who received placebo.

Table 5: PROactive Trial: Incidence and Types of Adverse Events Reported in > 5% of Patients Treated with ACTOS and More Commonly than Placebo

  % of Patients
Placebo
N=2633
ACTOS
N=2605
Hypoglycemia 18.8 27.3
Edema 15.3 26.7
Cardiac Failure 6.1 8.1
Pain in Extremity 5.7 6.4
Back Pain 5.1 5.5
Chest Pain 5 5.1
Mean duration of patient follow-up was 34.5 months.

Congestive Heart Failure

A summary of the incidence of adverse events related to congestive heart failure is provided in Table 6 for the 16-to 24-week add-on to sulfonylurea trials, for the 16-to 24-week add-on to insulin trials, and for the 16-to 24-week add-on to metformin trials. None of the events were fatal.

Table 6: Treatment-Emergent Adverse Events of Congestive Heart Failure (CHF)

  Patients Treated with ACTOS or Placebo Added on to a Sulfonylurea
Number (%) of Patients
Placebo-Controlled Trial (16 weeks) Non-Controlled Double-Blind Trial (24 weeks)
Placebo + Sulfonylurea
N=187
ACTOS 15 mg + Sulfonylurea
N=184
ACTOS 30 mg + Sulfonylurea
N=189
ACTOS 30 mg + Sulfonylurea
N=351
ACTOS 45 mg + Sulfonylurea
N=351
At least one congestive heart failure event 2 (1.1%) 0 0 1 (0.3%) 6 (1.7%)
Hospitalized 2 (1.1%) 0 0 0 2 (0.6%)
  Patients Treated with ACTOS or Placebo Added on to Insulin
Number (%) of Patients
Placebo-Controlled Trial (16 weeks) Non-Controlled Double-Blind Trial (24 weeks)
Placebo + Insulin
N=187
ACTOS 15 mg + Insulin
N=191
ACTOS 30 mg + Insulin
N=188
ACTOS 30 mg + Insulin
N=345
ACTOS 45 mg + Insulin
N=345
At least one congestive heart failure event 0 2 (1.0%) 2 (1.1%) 3 (0.9%) 5 (1.4%)
Hospitalized 0 2 (1.0%) 1 (0.5%) 1 (0.3%) 3 (0.9%)
  Patients Treated with ACTOS or Placebo Added on to Metformin
Number (%) of Patients
Placebo-Controlled Trial (16 weeks) Non-Controlled Double-Blind Trial (24 weeks)
Placebo + Metformin
N=160
ACTOS 30 mg + Metformin
N=168
ACTOS 30 mg + Metformin
N=411
ACTOS 45 mg + Metformin
N=416
 
At least one congestive heart failure event 0 1 (0.6%) 0 1 (0.2%)  
Hospitalized 0 1 (0.6%) 0 1 (0.2%)  

Patients with type 2 diabetes and NYHA class II or early class III congestive heart failure were randomized to receive 24 weeks of double-blind treatment with either ACTOS at daily doses of 30 mg to 45 mg (n=262) or glyburide at daily doses of 10 mg to 15 mg (n=256). A summary of the incidence of adverse events related to congestive heart failure reported in this study is provided in Table 7.

Table 7: Treatment-Emergent Adverse Events of Congestive Heart Failure (CHF) in Patients with NYHA Class II or III Congestive Heart Failure Treated with ACTOS or Glyburide

  Number (%) of Subjects
ACTOS
N=262
Glyburide
N=256
Death due to cardiovascular causes (adjudicated) 5 (1.9%) 6 (2.3%)
Overnight hospitalization for worsening CHF (adjudicated) 26 (9.9%) 12 (4.7%)
Emergency room visit for CHF (adjudicated) 4 (1.5%) 3 (1.2%)
Patients experiencing CHF progression during study 35 (13.4%) 21 (8.2%)

Congestive heart failure events leading to hospitalization that occurred during the PROactive trial are summarized in Table 8.

Table 8: Treatment-Emergent Adverse Events of Congestive Heart Failure (CHF) in PROactive Trial

  Number (%) of Patients
Placebo
N=2633
ACTOS
N=2605
At least one hospitalized congestive heart failure event 108 (4.1%) 149 (5.7%)
Fatal 22 (0.8%) 25 (1.0%)
Hospitalized, nonfatal 86 (3.3%) 124 (4.7%)

Cardiovascular Safety

In the PROactive trial, 5238 patients with type 2 diabetes and a history of macrovascular disease were randomized to ACTOS (N=2605), force-titrated up to 45 mg daily or placebo (N=2633) in addition to standard of care. Almost all patients (95%) were receiving cardiovascular medications (beta blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, nitrates, diuretics, aspirin, statins and fibrates). At baseline, patients had a mean age of 62 years, mean duration of diabetes of 9.5 years, and mean HbA1c of 8.1%. Mean duration of follow-up was 34.5 months.

The primary objective of this trial was to examine the effect of ACTOS on mortality and macrovascular morbidity in patients with type 2 diabetes mellitus who were at high risk for macrovascular events. The primary efficacy variable was the time to the first occurrence of any event in a cardiovascular composite endpoint that included all-cause mortality, nonfatal myocardial infarction (MI) including silent MI, stroke, acute coronary syndrome, cardiac intervention including coronary artery bypass grafting or percutaneous intervention, major leg amputation above the ankle, and bypass surgery or revascularization in the leg. A total of 514 (19.7%) patients treated with ACTOS and 572 (21.7%) placebo-treated patients experienced at least one event from the primary composite endpoint (hazard ratio 0.90; 95% Confidence Interval: 0.80, 1.02; p=0.10).

Although there was no statistically significant difference between ACTOS and placebo for the three-year incidence of a first event within this composite, there was no increase in mortality or in total macrovascular events with ACTOS. The number of first occurrences and total individual events contributing to the primary composite endpoint is shown in Table 9.

Table 9: PROactive: Number of First and Total Events for Each Component within the Cardiovascular Composite Endpoint

Cardiovascular Events Placebo
N=2633
ACTOS
N=2605
First Events
n (%)
Total events
n
First Events
n (%)
Total events
n
Any event 572 (21.7) 900 514 (19.7) 803
  All-cause mortality 122 (4.6) 186 110 (4.2) 177
  Nonfatal myocardial infarction (MI) 118 (4.5) 157 105 (4.0) 131
  Stroke 96 (3.6) 119 76 (2.9) 92
  Acute coronary syndrome 63 (2.4) 78 42 (1.6) 65
  Cardiac intervention (CABG/PCI) 101 (3.8) 240 101 (3.9) 195
  Major leg amputation 15 (0.6) 28 9 (0.3) 28
  Leg revascularization 57 (2.2) 92 71 (2.7) 115
CABG = coronary artery bypass grafting; PCI = percutaneous intervention

Weight Gain

Dose-related weight gain occurs when ACTOS is used alone or in combination with other antidiabetic medications. The mechanism of weight gain is unclear but probably involves a combination of fluid retention and fat accumulation.

Tables 10 and 11 summarize the changes in body weight with ACTOS and placebo in the 16-to 26-week randomized, double-blind monotherapy and 16-to 24-week combination add-on therapy trials and in the PROactive trial.

Table 10: Weight Changes (kg) from Baseline During Randomized, Double-Blind Clinical Trials

    Control Group (Placebo) ACTOS 15 mg ACTOS 30 mg ACTOS 45 mg
Median (25th/75th percentile) Median (25th/75th percentile) Median (25th/75th percentile) Median (25th/75th percentile)
Monotherapy (16 to 26 weeks)   -1.4 (-2.7/0.0) N=256 0.9 (-0.5/3.4) N=79 1.0 (-0.9/3.4) N=188 2.6 (0.2/5.4) N=79
Combination Therapy (16 to 24 weeks) Sulfonylurea -0.5 (-1.8/0.7) N=187 2.0 (0.2/3.2) N=183 3.1 (1.1/5.4) N=528 4.1 (1.8/7.3) N=333
Metformin -1.4 (-3.2/0.3) N=160 N/A 0.9 (-1.3/3.2) N=567 1.8 (-0.9/5.0) N=407
Insulin 0.2 (-1.4/1.4) N=182 2.3 (0.5/4.3) N=190 3.3 (0.9/6.3) N=522 4.1 (1.4/6.8) N=338

Table 11: Median Change in Body Weight in Patients Treated with ACTOS Versus Patients Treated with Placebo During the Double-Blind Treatment Period in the PROactive Trial

  Placebo ACTOS
Median (25th/75th percentile) Median (25th/75th percentile)
Change from baseline to final visit (kg) -0.5 (-3.3, 2.0) N=2581 +3.6 (0.0, 7.5) N=2560
Note: Median exposure for both ACTOS and Placebo was 2.7 years.

>
Edema

Edema induced from taking ACTOS is reversible when ACTOS is discontinued. The edema usually does not require hospitalization unless there is coexisting congestive heart failure. A summary of the frequency and types of edema adverse events occurring in clinical investigations of ACTOS is provided in Table 12.

Table 12: Adverse Events of Edema in Patients Treated with ACTOS

    Number (%) of Patients
Placebo ACTOS 15 mg ACTOS 30 mg ACTOS 45 mg
Monotherapy (16 to 26 weeks)   3 (1.2%) N=259 2 (2.5%) N= 81 13 (4.7%) N= 275 11 (6.5%) N=169
Combined Therapy (16 to 24 weeks) Sulfonylurea 4 (2.1%) N=187 3 (1.6%) N=184 61 (11.3%) N=540 81 (23.1%) N=351
Metformin 4 (2.5%) N=160 N/A 34 (5.9%) N=579 58 (13.9%) N=416
Insulin 13 (7.0%) N=187 24 (12.6%) N=191 109 (20.5%) N=533 90 (26.1%) N=345
Note: The preferred terms of edema peripheral, generalized edema, pitting edema and fluid retention were combined to form the aggregate term of “edema.”

Table 13: Adverse Events of Edema in Patients in the PROactive Trial

Number (%) of Patients
Placebo
N=2633
ACTOS
N=2605
419 (15.9%) 712 (27.3%)
Note: The preferred terms of edema peripheral, generalized edema, pitting edema and fluid retention were combined to form the aggregate term of “edema.”

Hepatic Effects

There has been no evidence of induced hepatotoxicity with ACTOS in the ACTOS controlled clinical trial database to date. One randomized, double-blind 3-year trial comparing ACTOS to glyburide as add-on to metformin and insulin therapy was specifically designed to evaluate the incidence of serum ALT elevation to greater than three times the upper limit of the reference range, measured every eight weeks for the first 48 weeks of the trial then every 12 weeks thereafter. A total of 3/1051 (0.3%) patients treated with ACTOS and 9/1046 (0.9%) patients treated with glyburide developed ALT values greater than three times the upper limit of the reference range. None of the patients treated with ACTOS in the ACTOS controlled clinical trial database to date have had a serum ALT greater than three times the upper limit of the reference range and a corresponding total bilirubin greater than two times the upper limit of the reference range, a combination predictive of the potential for severe drug-induced liver injury.

Hypoglycemia

In the ACTOS clinical trials, adverse events of hypoglycemia were reported based on clinical judgment of the investigators and did not require confirmation with fingerstick glucose testing.

In the 16-week add-on to sulfonylurea trial, the incidence of reported hypoglycemia was 3.7% with ACTOS 30 mg and 0.5% with placebo. In the 16-week add-on to insulin trial, the incidence of reported hypoglycemia was 7.9% with ACTOS 15 mg, 15.4% with ACTOS 30 mg, and 4.8% with placebo.

The incidence of reported hypoglycemia was higher with ACTOS 45 mg compared to ACTOS 30 mg in both the 24-week add-on to sulfonylurea trial (15.7% vs. 13.4%) and in the 24-week add-on to insulin trial (47.8% vs. 43.5%).

Three patients in these four trials were hospitalized due to hypoglycemia. All three patients were receiving ACTOS 30 mg (0.9%) in the 24-week add-on to insulin trial. An additional 14 patients reported severe hypoglycemia (defined as causing considerable interference with patient's usual activities) that did not require hospitalization. These patients were receiving ACTOS 45 mg in combination with sulfonylurea (n=2) or ACTOS 30 mg or 45 mg in combination with insulin (n=12).

Urinary Bladder Tumors

Tumors were observed in the urinary bladder of male rats in the two-year carcinogenicity study [see Nonclinical Toxicology]. In two 3-year trials in which ACTOS was compared to placebo or glyburide, there were 16/3656 (0.44%) reports of bladder cancer in patients taking ACTOS compared to 5/3679 (0.14%) in patients not taking ACTOS. After excluding patients in whom exposure to study drug was less than one year at the time of diagnosis of bladder cancer, there were six (0.16%) cases on ACTOS and two (0.05%) cases on placebo. There are too few events of bladder cancer to establish causality.

Laboratory Abnormalities

Hematologic Effects

ACTOS may cause decreases in hemoglobin and hematocrit. In placebo-controlled monotherapy trials, mean hemoglobin values declined by 2% to 4% in patients treated with ACTOS compared with a mean change in hemoglobin of -1% to +1% in placebo-treated patients. These changes primarily occurred within the first 4 to 12 weeks of therapy and remained relatively constant thereafter. These changes may be related to increased plasma volume associated with ACTOS therapy and are not likely to be associated with any clinically significant hematologic effects.

Creatine Phosphokinase

During protocol-specified measurement of serum creatine phosphokinase (CPK) in ACTOS clinical trials, an isolated elevation in CPK to greater than 10 times the upper limit of the reference range was noted in nine (0.2%) patients treated with ACTOS (values of 2150 to 11400 IU/L) and in no comparator-treated patients. Six of these nine patients continued to receive ACTOS, two patients were noted to have the CPK elevation on the last day of dosing and one patient discontinued ACTOS due to the elevation. These elevations resolved without any apparent clinical sequelae. The relationship of these events to ACTOS therapy is unknown.

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of ACTOS. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Postmarketing reports of congestive heart failure have been reported in patients treated with ACTOS, both with and without previously known heart disease and both with and without concomitant insulin administration.

In postmarketing experience, there have been reports of unusually rapid increases in weight and increases in excess of that generally observed in clinical trials. Patients who experience such increases should be assessed for fluid accumulation and volume-related events such as excessive edema and congestive heart failure [see BOXED WARNING and WARNINGS AND PRECAUTIONS].

Read the Actos (pioglitazone hydrochloride) Side Effects Center for a complete guide to possible side effects

DRUG INTERACTIONS

Strong CYP2C8 Inhibitors

An inhibitor of CYP2C8 (e.g., gemfibrozil) significantly increases the exposure (area under the serum concentration-time curve or AUC) and half-life (t½) of pioglitazone. Therefore, the maximum recommended dose of ACTOS is 15 mg daily if used in combination with gemfibrozil or other strong CYP2C8 inhibitors [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].

CYP2C8 Inducers

An inducer of CYP2C8 (e.g., rifampin) may significantly decrease the exposure (AUC) of pioglitazone. Therefore, if an inducer of CYP2C8 is started or stopped during treatment with ACTOS, changes in diabetes treatment may be needed based on clinical response without exceeding the maximum recommended daily dose of 45 mg for ACTOS [see CLINICAL PHARMACOLOGY].

Read the Actos Drug Interactions Center for a complete guide to possible interactions

Last reviewed on RxList: 11/25/2013
This monograph has been modified to include the generic and brand name in many instances.

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