Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack · SciRah

^aFrom the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut
^bAlpert Medical School, Brown University, Providence, RI (K.L.F.)
^cVermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.)
^dHôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada
^eUniversity of L'Aquila, L'Aquila, Italy (A.C.)
^fOregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the Univer
^gSchool of Medicine, Yale University, New Haven
^hAlpert Medical School, Brown University, Providence, RI
ⁱVermont College of Medicine, Burlington
^jConnecticut HealthCare System, West Haven
^kSchool of Public Health, Yale University, New Haven
^lNational Institute of Neurological Disorders and Stroke, Bethesda, MD
^mVA Medical Center and the University of Colorado School of Medicine, Denver
ⁿHôpital Charles LeMoyne, Greenfield Park, QC
^oUniversity of L'Aquila, L'Aquila, Italy
^pOregon Health Sciences University, Portland
^qUniversity of Arizona, Tucson
^rUniversity of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom
^sUniversity of Cincinnati, Cincinnati
^tJohn Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
^uUniversity of Heidelberg, Heidelberg, Germany
^vUniversity of South Carolina School of Medicine, Columbia
^wUniversity of Western Ontario, London
^xSheba Medical Center, Tel Aviv University, Tel Aviv, Israel
^yIllinois Neurological Institute–OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria
^zCenter for Neurological Research, Lethbridge, AB

Abstract

BACKGROUND: Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. METHODS: In this multicenter, double-blind trial, we randomly assigned 3876 patients 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. RESULTS: By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003). CONCLUSIONS: In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, 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. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).

TL;DRIn this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. (Semantic Scholar)

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Abstract

Plain-language summary

Discussion