Pioglitazone

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 pioglitazone tablets is provided in Table 12.

Table 12. Adverse Events of Edema in Patients Treated with Pioglitazone Hydrochloride

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

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 in the pioglitazone hydrochloride controlled clinical trial database to date. One randomized, double-blind, 3-year trial comparing pioglitazone hydrochloride 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 twelve weeks thereafter. A total of 3/1051 (0.3%) patients treated with pioglitazone hydrochloride 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  pioglitazone hydrochloride in the pioglitazone hydrochloride 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 pioglitazone hydrochloride 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 pioglitazone hydrochloride 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 pioglitazone hydrochloride 15 mg, 15.4% with Pioglitazone Hydro chloride 30 mg, and 4.8% with placebo.

The incidence of reported hypoglycemia was higher with  pioglitazone hydrochloride 45 mg compared to pioglitazone hydrochloride 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 pioglitazone hydrochloride 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 pioglitazone hydrochloride 45 mg in combination with sulfonylurea (n=2) or pioglitazone hydrochloride 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 ( 13.1 )]. In two 3-year trials in which pioglitazone hydrochloride was compared to placebo or glyburide, there were 16/3656 (0.44%) reports of bladder cancer in patients taking pioglitazone hydrochloride compared to 5/3679 (0.14%) in patients not taking pioglitazone hydrochloride. 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 pioglitazone hydrochloride and two (0.05%) cases on placebo. There are too few events of bladder cancer to establish causality.

Laboratory Abnormalities

Hematologic Effects:
Pioglitazone hydrochloride may cause decreases in hemoglobin and hematocrit. In placebo-controlled monotherapy trials, mean hemoglobin values declined by 2% to 4% in patients treated with pioglitazone hydrochloride 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 pioglitazone hydrochloride 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 pioglitazone hydrochloride clinical trials, an isolated elevation in CPK to greater than 10 times the upper limit of the reference range was noted in 9 (0.2%) patients treated with  Pioglitazone Hydro chloride (values of 2150 to 11400 IU/L) and in no comparator-treated patients. Six of these nine patients continued to receive pioglitazone hydrochloride, two patients were noted to have the CPK elevation on the last day of dosing and one patient discontinued Pioglitazone Hydro chloride due to the elevation. These elevations resolved without any apparent clinical sequelae. The relationship of these events to pioglitazone hydrochloride therapy is unknown.

6.2 Postmarketing Experience

The following adverse reactions have been identified during post-approval use of pioglitazone hydrochloride. 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.

• New onset or worsening diabetic macular edema with decreased visual acuity [see Warnings and Precautions (5.7 )].
• Fatal and nonfatal hepatic failure [see Warnings and Precautions ( 5.3 )].

Postmarketing reports of congestive heart failure have been reported in patients treated with pioglitazone hydrochloride, 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 ( 5.1 )].

7 DRUG INTERACTIONS

7.1 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 (t1/2) of pioglitazone. Therefore, the maximum recommended dose of pioglitazone hydrochloride is 15 mg daily if used in combination with gemfibrozil or other strong CYP2C8 inhibitors [see Dosage and Administration (2.3) and Clinical Pharmacology (12.3)].

7.2 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 pioglitazone hydrochloride, changes in diabetes treatment may be needed based on clinical response without exceeding the maximum recommended daily dose of 45 mg for pioglitazone hydrochloride [see Clinical Pharmacology ( 12.3 )].

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Teratogenic Effects
Pregnancy Category C.
There are no adequate and well-controlled studies of pioglitazone hydrochloride in pregnant women. Animal studies show increased rates of post-implantation loss, delayed development, reduced fetal weights, and delayed parturition at doses 10 to 40 times the maximum recommended human dose. Pioglitazone hydrochloride should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Clinical Considerations:
Abnormal blood glucose concentrations during pregnancy are associated with a higher incidence of congenital anomalies, as well as increased neonatal morbidity and mortality. Most experts recommend the use of insulin during pregnancy to maintain blood glucose concentrations as close to normal as possible for patients with diabetes.

Animal Data:
In animal reproductive studies, pregnant rats and rabbits received pioglitazone at doses up to approximately 17 (rat) and 40 (rabbit) times the maximum recommended human oral dose (MRHD) based on body surface area (mg/m²); no teratogenicity was observed. Increases in embryotoxicity (increased postimplantation losses, delayed development, reduced fetal weights, and delayed parturition) occurred in rats that received oral doses approximately 10 or more times the MRHD (mg/m² basis). No functional or behavioral toxicity was observed in rat offspring. When pregnant rats received pioglitazone during late gestation and lactation, delayed postnatal development, attributed to decreased body weight, occurred in rat offspring at oral maternal doses approximately two or more times the MRHD (mg/m² basis). In rabbits, embryotoxicity occurred at oral doses approximately 40 times the MRHD (mg/m² basis).

8.3 Nursing Mothers

It is not known whether pioglitazone hydrochloride is secreted in human milk. Pioglitazone is secreted in the milk of lactating rats. Because many drugs are excreted in human milk, and because of the potential for pioglitazone hydrochloride to cause serious adverse reactions in nursing infants, a decision should be made to discontinue nursing or discontinue pioglitazone hydrochloride, taking into account the importance of pioglitazone hydrochloride to the mother.

8.4 Pediatric Use

Safety and effectiveness of pioglitazone hydrochloride in pediatric patients have not been established.

Pioglitazone hydrochloride is not recommended for use in pediatric patients based on adverse effects observed in adults, including fluid retention and congestive heart failure, fractures, and urinary bladder tumors [see Warnings and Precautions (5.1, 5.4, 5.5 and 5.6)].

8.5 Geriatric Use

A total of 92 patients (15.2%) treated with pioglitazone hydrochloride in the three pooled 16- to 26-week double-blind, placebo-controlled, monotherapy trials were ≥ 65 years old and  two patients (0.3%) were ≥ 75 years old. In the two pooled 16- to 24-week add-on to sulfonylurea trials, 201 patients (18.7 %) treated with pioglitazone hydrochloride were ≥ 65 years old and 19 (1.8%) were ≥ 75 years old. In the two pooled 16- to 24- week add-on to metformin trials, 155 patients (15.5%) treated with pioglitazone hydrochloride were ≥ 65 years old and 19 (1.9%) were ≥ 75 years old. In the two pooled 16- to 24- week add-on to insulin trials, 272 patients (25.4%) treated with pioglitazone hydrochloride were ≥ 65 years old and 22 (2.1%) were ≥ 75 years old.

In PROactive, 1068 patients (41.0%) treated with pioglitazone hydrochloride were ≥ 65 years old and 42 (1.6%) were ≥ 75 years old.

In pharmacokinetic studies with pioglitazone, no significant differences were observed in pharmacokinetic parameters between elderly and younger patients [see Clinical Pharmacology (12.3)].

Although clinical experiences have not identified differences in effectiveness and safety between the elderly (≥ 65 years) and younger patients, these conclusions are limited by small sample sizes for patients ≥ 75 years old.

10 OVERDOSAGE

During controlled clinical trials, one case of overdose with pioglitazone hydrochloride was reported. A male patient took 120 mg per day for four days, then 180 mg per day for seven days. The patient denied any clinical symptoms during this period.

In the event of overdosage, appropriate supportive treatment should be initiated according to the patient's clinical signs and symptoms.

11 DESCRIPTION

Pioglitazone tablets USP are a thiazolidinedione and an agonist for peroxisome proliferator-activated receptor (PPAR) gamma that contains an oral antidiabetic medication: pioglitazone.

Pioglitazone [(±)-5-[[4-[2-(5-ethyl-2-pyridinyl) ethoxy] phenyl] methyl]-2,4-] thiazolidinedione monohydrochloride contains one asymmetric carbon, and the compound is synthesized and used as the racemic mixture. The two enantiomers of pioglitazone interconvert in vivo. No differences were found in the pharmacologic activity between the two enantiomers. The structural formula is as shown:

Pioglitazone hydrochloride, USP is an odorless white crystalline powder that has a molecular formula of C₁₉H₂₀N₂O₃S•HCl and a molecular weight of 392.90 daltons. It is soluble in N,N-dimethylformamide, slightly soluble in anhydrous ethanol, very slightly soluble in acetone and acetonitrile, practically insoluble in water, and insoluble in ether.

Pioglitazone hydrochloride USP is available as a tablet for oral administration containing 15 mg, 30 mg, or 45 mg of pioglitazone (as the base) formulated with the following excipients: lactose monohydrate, hydroxypropylcellulose, carboxymethylcellulose calcium, and magnesium stearate.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Pioglitazone hydrochloride is a thiazolidinedione that depends on the presence of insulin for its mechanism of action. Pioglitazone hydrochloride decreases insulin resistance in the periphery and in the liver resulting in increased insulin-dependent glucose disposal and decreased hepatic glucose output. Pioglitazone is not an insulin secretagogue. Pioglitazone is an agonist for peroxisome proliferator-activated receptor-gamma (PPARγ). PPAR receptors are found in tissues important for insulin action such as adipose tissue, skeletal muscle, and liver. Activation of PPARγ nuclear receptors modulates the transcription of a number of insulin responsive genes involved in the control of glucose and lipid metabolism.

In animal models of diabetes, pioglitazone reduces the hyperglycemia, hyperinsulinemia, and hypertriglyceridemia characteristic of insulin-resistant states such as type 2 diabetes. The metabolic changes produced by pioglitazone result in increased responsiveness of insulin-dependent tissues and are observed in numerous animal models of insulin resistance.

Because pioglitazone enhances the effects of circulating insulin (by decreasing insulin resistance), it does not lower blood glucose in animal models that lack endogenous insulin.

12.2 Pharmacodynamics

Clinical studies demonstrate that pioglitazone hydrochloride improves insulin sensitivity in insulin-resistant patients. Pioglitazone hydrochloride enhances cellular responsiveness to insulin, increases insulin-dependent glucose disposal and improves hepatic sensitivity to insulin. In patients with type 2 diabetes, the decreased insulin resistance produced by pioglitazone hydrochloride results in lower plasma glucose concentrations, lower plasma insulin concentrations, and lower HbA1c values. In controlled clinical trials, pioglitazone hydrochloride had an additive effect on glycemic control when used in combination with a sulfonylurea, metformin, or insulin [see Clinical Studies ( 14.2 )].

Patients with lipid abnormalities were included in clinical trials with pioglitazone hydrochloride. Overall, patients treated with pioglitazone hydrochloride had mean decreases in serum triglycerides, mean increases in HDL cholesterol, and no consistent mean changes in LDL and total cholesterol. There is no conclusive evidence of macrovascular benefit with pioglitazone hydrochloride or any other antidiabetic medication [see Warnings and Precautions ( 5.8 ) and Adverse Reactions ( 6.1 )].

In a 26-week, placebo-controlled, dose-ranging monotherapy study, mean serum triglycerides decreased in the 15 mg, 30 mg, and 45 mg pioglitazone hydrochloride dose groups compared to a mean increase in the placebo group. Mean HDL cholesterol increased to a greater extent in patients treated with pioglitazone hydrochloride than in the placebo-treated patients. There were no consistent differences for LDL and total cholesterol in patients treated with pioglitazone hydrochloride compared to placebo (see Table 14).

Table 14. Lipids in a 26-Week Placebo-Controlled Monotherapy Dose-Ranging Study

	Placebo	Pioglitazone Hydrochloride 15 mg Once Daily	Pioglitazone Hydrochloride 30 mg Once Daily	Pioglitazone Hydrochloride 45 mg Once Daily
Triglycerides (mg/dL)	N=79	N=79	N=84	N=77
Baseline (mean)	263	284	261	260
Percent change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	4.8%	-9.0%p < 0.05 versus placebo	-9.6%p < 0.05 versus placebo	-9.3%p < 0.05 versus placebo
HDL Cholesterol (mg/dL)	N=79	N=79	N=83	N=77
Baseline (mean)	42	40	41	41
Percent change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	8.1%	14.1%	12.2%	19.1%
LDL Cholesterol (mg/dL)	N=65	N=63	N=74	N=62
Baseline (mean)	139	132	136	127
Percent change from baseline (adjusted mean)	4.8%	7.2%	5.2%	6.0%
Total Cholesterol (mg/dL)	N=79	N=79	N=84	N=77
Baseline (mean)	225	220	223	214
Percent change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	4.4%	4.6%	3.3%	6.4%

In the two other monotherapy studies (16 weeks and 24 weeks) and in combination therapy studies with sulfonylurea (16 weeks and 24 weeks), metformin (16 weeks and 24 weeks) or insulin (16 weeks and 24 weeks), the results were generally consistent with the data above.

12.3 Pharmacokinetics

Following once-daily administration of pioglitazone hydrochloride, steady-state serum concentrations of both pioglitazone and its major active metabolites, M-III (keto derivative of pioglitazone) and M-IV (hydroxyl derivative of pioglitazone), are achieved within 7 days. At steady-state, M-III and M-IV reach serum concentrations equal to or greater than that of pioglitazone. At steady-state, in both healthy volunteers and patients with type 2 diabetes, pioglitazone comprises approximately 30% to 50% of the peak total pioglitazone serum concentrations (pioglitazone plus active metabolites) and 20% to 25% of the total AUC.

C_max, AUC, and trough serum concentrations (C_min) for pioglitazone and M-III and M-IV, increased proportionally with administered doses of 15 mg and 30 mg per day.
Absorption:
Following oral administration of pioglitazone, T_max of pioglitazone was within two hours. Food  delays the T_max to  three to  four hours but does not alter the extent of absorption (AUC).

Distribution:
The mean apparent volume of distribution (Vd/F) of pioglitazone following single-dose administration is 0.63 ± 0.41 (mean ± SD) L/kg of body weight. Pioglitazone is extensively protein bound (> 99%) in human serum, principally to serum albumin. Pioglitazone also binds to other serum proteins, but with lower affinity. M-III and M-IV are also extensively bound (> 98%) to serum albumin.

Metabolism:
Pioglitazone is extensively metabolized by hydroxylation and oxidation; the metabolites also partly convert to glucuronide or sulfate conjugates. Metabolites M-III and M-IV are the major circulating active metabolites in humans.
In vitro data demonstrate that multiple CYP isoforms are involved in the metabolism of pioglitazone,  which include CYP2C8 and, to a lesser degree, CYP3A4 with additional contributions from a variety of other isoforms including the mainly extrahepatic CYP1A1. In vivo study of pioglitazone in combination with gemfibrozil, a strong CYP2C8 inhibitor, showed that pioglitazone is a CYP2C8 substrate  [see Dosage and Administration (2.3) and Drug Interactions (7)]. Urinary 6ß-hydroxycortisol/cortisol ratios measured in patients treated with pioglitazone hydrochloride showed that pioglitazone is not a strong CYP3A4 enzyme inducer.


Excretion and Elimination:
Following oral administration, approximately 15% to 30% of the pioglitazone dose is recovered in the urine. Renal elimination of pioglitazone is negligible, and the drug is excreted primarily as metabolites and their conjugates. It is presumed that most of the oral dose is excreted into the bile either unchanged or as metabolites and eliminated in the feces.
The mean serum half-life (t_1/2) of pioglitazone and its metabolites (M-III and M-IV) range from  three to  seven hours and 16 to 24 hours, respectively. Pioglitazone has an apparent clearance, CL/F, calculated to be  five to  seven L/hr.

Renal Impairment:
The serum elimination half-life of pioglitazone, M-III, and M-IV remains unchanged in patients with moderate (creatinine clearance [CLcr] 30 to 50 mL/min) and severe ( CLcr < 30 mL/min) renal impairment when compared to subjects with normal renal function. Therefore, no dose adjustment in patients with renal impairment is required.

Hepatic Impairment:
Compared with healthy controls, subjects with impaired hepatic function (Child-Turcotte-Pugh Grade B/C) have an approximate 45% reduction in pioglitazone and total pioglitazone (pioglitazone, M-III, and M-IV) mean Cmax but no change in the mean AUC values. Therefore, no dose adjustment in patients with hepatic impairment is required.
There are postmarketing reports of liver failure with pioglitazone hydrochloride and clinical trials have generally excluded patients with serum ALT >2.5 times the upper limit of the reference range. Use caution in patients with liver disease [see Warnings and Precautions (5.3)].

Geriatric Patients:
In healthy elderly subjects, Cmax of pioglitazone  was not significantly different, but AUC values  were approximately 21% higher than those achieved in younger subjects. The mean  t1/2 of pioglitazone  was also  prolonged in elderly subjects (about  ten hours) as compared to younger subjects (about  seven hours). These changes were not of a magnitude that would be considered clinically relevant.

Pediatric Patients:
Safety and efficacy of pioglitazone in pediatric patients have not been established. Pioglitazone hydrochloride is not recommended for use in pediatric patients [see Use in Specific Populations (8.4)].

Gender:
The mean Cmax and AUC values of pioglitazone were increased 20% to 60% in women compared to men. In controlled clinical trials, HbA1c decreases from baseline were generally greater for females than for males (average mean difference in HbA1c 0.5%). Because therapy should be individualized for each patient to achieve glycemic control, no dose adjustment is recommended based on gender alone.

Ethnicity:
Pharmacokinetic data among various ethnic groups are not available.

Drug-Drug Interactions

Table 15. Effect of Pioglitazone Coadministration on Systemic Exposure of Other Drugs

Coadministered Drug
Pioglitazone Dosage Regimen (mg)Daily for 7 days unless otherwise noted	Name and Dose Regimens	Change in AUC% change (with/without coadministered drug and no change = 0%); symbols of ↑ and ↓ indicate the exposure increase and decrease, respectively.		Change in  Cmax % change (with/without coadministered drug and no change = 0%); symbols of ↑ and ↓ indicate the exposure increase and decrease, respectively.
45 mg  (N = 12)	WarfarinPioglitazone has no clinically significant effect on prothrombin time
	Daily loading then maintenance doses   based PT and INR values Quick's Value = 35 ± 5%	R-Warfarin	↓ 3%	R-Warfarin	↓ 2%
		S-Warfarin	↓ 1%	S-Warfarin	↑ 1%
45 mg  (N = 12)	Digoxin
	0.200 mg twice daily (loading dose) then 0.250 mg daily (maintenance dose, 7 days)	↑ 15%		↑ 17%
45 mg daily  for 21 days  (N = 35)	Oral Contraceptive
	[Ethinyl Estradiol (EE) 0.035 mg plus Norethindrone (NE) 1 mg] for 21 days	EE	↓11%	EE	↓13%
		NE	↑ 3%	NE	↓7%
45 mg  (N = 23)	Fexofenadine
	60 mg twice daily for 7 days	↑ 30%		↑ 37%
45 mg  (N = 14)	Glipizide
	5 mg daily for 7 days	↓ 3%		↓ 8%
45 mg daily  for 8 days  (N = 16)	Metformin
	1000 mg single dose on Day 8	↓ 3%		↓ 5%
45 mg  (N = 21)	Midazolam
	7.5 mg single dose on Day 15	↓ 26%		↓ 26%
45 mg  (N = 24)	Ranitidine
	150 mg twice daily for 7 days	↑ 1%		↓1%
45 mg daily  for 4 days  (N = 24)	Nifedipine ER
	30 mg daily for 4 days	↓ 13%		↓ 17%
45 mg  (N = 25)	Atorvastatin Ca
	80 mg daily for 7 days	↓ 14%		↓ 23%
45 mg  (N = 22)	Theophylline
	400 mg twice daily for 7 days	↑ 2%		↑ 5%

Table 16. Effect of Coadministered Drugs on Pioglitazone Systemic Exposure

The half-life of pioglitazone increased from  8.3 hours to 22.7 hours in the presence of gemfibrozil  [see Dosage and Administration (2.3) and Drug Interactions (7)]
Coadministered Drug and Dosage Regimen	Pioglitazone
	Dose Regimen (mg)Daily for 7 days unless otherwise noted	Change        in AUCMean ratio (with/without coadministered drug and no change =1 fold ) % change (with/without coadministered drug and no change = 0%); symbols of ↑ and ↓indicate the exposure increase and decrease, respectively.	Change in C max Mean ratio (with/without coadministered drug and no change =1 fold ) % change (with/without coadministered drug and no change = 0%); symbols of ↑ and ↓indicate the exposure increase and decrease, respectively.
Gemfibrozil 600 mg twice daily for 2 days (N = 12)	30 mg single dose	↑ 3.4-fold‡	↑ 6%
Ketoconazole 200 mg twice daily for 7 days (N = 28)	45 mg	↑ 34%	↑ 14%
Rifampin 600 mg daily for 5 days (N = 10)	30 mg single dose	↓ 54%	↓ 5%
Fexofenadine 60 mg twice daily for 7 days (N = 23)	45 mg	↑ 1%	0%
Ranitidine 150 mg twice daily for 4 days (N = 23)	45 mg	↓ 13%	↓ 16%
Nifedipine ER 30 mg daily for 7 days (N = 23)	45 mg	↑ 5%	↑ 4%
Atorvastatin Ca 80 mg daily for 7 days (N = 24)	45 mg	↓ 24%	↓ 31%
Theophylline 400 mg twice daily for 7 days (N = 22)	45 mg	↓ 4%	↓ 2%

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis And Mutagenesis & Impairment Of Fertility

A two-year carcinogenicity study was conducted in male and female rats at oral doses up to 63 mg/kg (approximately 14 times the maximum recommended human oral dose of 45 mg based on mg/m²). Drug-induced tumors were not observed in any organ except for the urinary bladder of male rats. Benign and/or malignant transitional cell neoplasms were observed in male rats at 4 mg/kg/day and above (approximately equal to the maximum recommended human oral dose based on mg/m²). Urinary calculi with subsequent irritation and hyperplasia were postulated as the mechanism for bladder tumors observed in male rats. A two-year mechanistic study in male rats utilizing dietary acidification to reduce calculi formation was completed in 2009. Dietary acidification decreased but did not abolish the hyperplastic changes in the bladder. The presence of calculi exacerbated the hyperplastic response to pioglitazone but was not considered the primary cause of the hyperplastic changes.

The relevance to humans of the bladder findings in the male rat cannot be excluded.

A two-year carcinogenicity study was also conducted in male and female mice at oral doses up to 100 mg/kg/day (approximately 11 times the maximum recommended human oral dose based on mg/m²). No drug-induced tumors were observed in any organ.

Pioglitazone hydrochloride was not mutagenic in a battery of genetic toxicology studies, including the Ames bacterial assay, a mammalian cell forward gene mutation assay (CHO/HPRT and AS52/XPRT), an in vitro cytogenetics assay using CHL cells, an unscheduled DNA synthesis assay, and an in vivo micronucleus assay.

No adverse effects upon fertility were observed in male and female rats at oral doses up to 40 mg/kg pioglitazone hydrochloride daily prior to and throughout mating and gestation (approximately  nine times the maximum recommended human oral dose based on mg/m²).

13.2 Animal Pharmacology And OR Toxicology

Heart enlargement has been observed in mice(100 mg/kg), rats (4 mg/kg and above) and dogs(3 mg/kg) treated orally with pioglitazone hydrochloride (approximately 11, 1, and 2 times the maximum recommended human oral dose for mice, rats, and dogs, respectively, based on mg/m²). In a one-year rat study, drug-related early death due to apparent heart dysfunction occurred at an oral dose of 160 mg/kg/day (approximately 35 times the maximum recommended human oral dose based on mg/m²). Heart enlargement was seen in a 13-week study in monkeys at oral doses of 8.9 mg/kg and above (approximately four times the maximum recommended human oral dose based on mg/m²), but not in a 52-week study at oral doses up to 32 mg/kg (approximately 13 times the maximum recommended human oral dose based on mg/m²).

14 CLINICAL STUDIES

14.1 Monotherapy

Three randomized, double-blind, placebo-controlled trials with durations from 16 to 26 weeks were conducted to evaluate the use of pioglitazone hydrochloride as monotherapy in patients with type 2 diabetes. These trials examined pioglitazone hydrochloride at doses up to 45 mg or placebo once daily in a total of 865 patients.

In a 26-week dose-ranging monotherapy trial, 408 patients with type 2 diabetes were randomized to receive 7.5 mg, 15 mg, 30 mg, or 45 mg of pioglitazone hydrochloride, or placebo once daily. Therapy with any previous antidiabetic agent was discontinued 8 weeks prior to the double-blind period. Treatment with 15 mg, 30 mg, and 45 mg of pioglitazone hydrochloride produced statistically significant improvements in HbA1c and fasting plasma glucose (FPG) at endpoint compared to placebo (see Figure 1, Table 17).

Figure 1 shows the time course for changes in HbA1c in this 26-week study.

Figure 1. Mean Change from Baseline for HbA1c in a 26-Week Placebo-Controlled Dose-Ranging Study (Observed Values)

Table 17. Glycemic Parameters in a 26-Week Placebo-Controlled Dose-Ranging Monotherapy Trial

	Placebo	Pioglitazone Hydrochloride 15 mg Once Daily	Pioglitazone Hydrochloride 30 mg Once Daily	Pioglitazone Hydrochloride 45 mg Once Daily
Total Population
HbA1c (%)	N=79	N=79	N=85	N=76
Baseline (mean)	10.4	10.2	10.2	10.3
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	0.7	-0.3	-0.3	-0.9
Difference from placebo                         (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-1.0 p ≤ 0.05 vs. placebo (-1.6, -0.4)	-1.0p ≤ 0.05 vs. placebo    (-1.6, -0.4)	-1.6p ≤ 0.05 vs. placebo    (-2.2, -1.0)
Fasting Plasma Glucose (mg/dL)	N=79	N=79	N=84	N=77
Baseline (mean)	268	267	269	276
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	9	-30	-32	-56
Difference from placebo                  (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-39p ≤ 0.05 vs. placebo (-63, -16)	-41 p ≤ 0.05 vs. placebo (-64, -18)	-65p ≤ 0.05 vs. placebo    (-89, -42)

In a 24-week placebo-controlled monotherapy trial, 260 patients with type 2 diabetes were randomized to one of two forced-titration pioglitazone hydrochloride treatment groups or a mock-titration placebo group. Therapy with any previous antidiabetic agent was discontinued 6 weeks prior to the double-blind period. In one pioglitazone hydrochloride treatment group, patients received an initial dose of 7.5 mg once daily. After four weeks, the dose was increased to 15 mg once daily and after another four weeks, the dose was increased to 30 mg once daily for the remainder of the trial (16 weeks). In the second pioglitazone hydrochloride treatment group, patients received an initial dose of 15 mg once daily and were titrated to 30 mg once daily and 45 mg once daily in a similar manner. Treatment with pioglitazone hydrochloride, as described, produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo (see Table 18).
Table 18. Glycemic Parameters in a 24-Week Placebo-Controlled Forced-Titration Monotherapy Trial

	Placebo	Pioglitazone Hydrochloride 30 mgFinal dose in forced titration Once Daily	Pioglitazone Hydrochloride 45 mgFinal dose in forced titration Once Daily
Total Population
HbA1c (%)	N=83	N=85	N=85
Baseline (mean)	10.8	10.3	10.8
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	0.9	-0.6	-0.6
Difference from placebo (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-1.5p ≤ 0.05 vs. placebo (-2.0, -1.0)	-1.5p ≤ 0.05 vs. placebo (-2.0, -1.0)
Fasting Plasma Glucose (mg/dL)	N=78	N=82	N=85
Baseline (mean)	279	268	281
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	18	-44	-50
Difference from placebo (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-62p ≤ 0.05 vs. placebo (-82, -.41)	-68p ≤ 0.05 vs. placebo (-88, -.48)

In a 16-week monotherapy trial, 197 patients with type 2 diabetes were randomized to treatment with 30 mg of pioglitazone hydrochloride or placebo once daily. Therapy with any previous antidiabetic agent was discontinued 6 weeks prior to the double-blind period. Treatment with 30 mg of pioglitazone hydrochloride produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo (see Table 19)

Table 19. Glycemic Parameters in a 16-Week Placebo-Controlled Monotherapy Trial

	Placebo	Pioglitazone Hydrochloride 30 mg Once Daily
Total Population
HbA1c (%)	N=93	N=100
Baseline (mean)	10.3	10.5
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	0.8	-0.6
Difference from placebo (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-1.4p ≤ 0.05 vs. placebo (-1.8, -0.9)
Fasting Plasma Glucose (mg/dL)	N=91	N=99
Baseline (mean)	270	273
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	8	-50
Difference from placebo (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-58p ≤ 0.05 vs. placebo (-77, -38)

14.2 Combination Therapy

Three 16-week, randomized, double-blind, placebo-controlled clinical trials were conducted to evaluate the effects of pioglitazone hydrochloride (15 mg and/or 30 mg) on glycemic control in patients with type 2 diabetes who were inadequately controlled (HbA1c ≥ 8%) despite current therapy with a sulfonylurea, metformin, or insulin. In addition, three 24-week randomized, double-blind clinical trials were conducted to evaluate the effects of pioglitazone hydrochloride 30 mg vs. pioglitazone hydrochloride 45 mg on glycemic control in patients with type 2 diabetes who were inadequately controlled (HbA1c ≥ 8%) despite current therapy with a sulfonylurea, metformin, or insulin. Previous diabetes treatment may have been monotherapy or combination therapy.

Add-on to Sulfonylurea Trials:
Two clinical trials were conducted with pioglitazone hydrochloride in combination with a sulfonylurea. Both studies included patients with type 2 diabetes on any dose of a sulfonylurea, either alone or in combination with another antidiabetic agent. All other antidiabetic agents were withdrawn at least 3 weeks prior to starting study treatment.

In the first study, 560 patients were randomized to receive 15 mg or 30 mg of pioglitazone hydrochloride or placebo once daily for 16 weeks in addition to their current sulfonylurea regimen. Treatment with pioglitazone hydrochloride as add-on to sulfonylurea produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo add-on to sulfonylurea (see Table 20).

Table 20. Glycemic Parameters in a 16-Week Placebo-Controlled, Add-on to Sulfonylurea Trial

	Placebo + Sulfonylurea	Pioglitazone  Hydrochloride 15 mg + Sulfonylurea	Pioglitazone Hydrochloride 30 mg + Sulfonylurea
Total Population
HbA1c (%)	N=181	N=176	N=182
Baseline (mean)	9.9	10.0	9.9
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	0.1	-0.8	-1.2
Difference from placebo + sulfonylurea  (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-0.9p ≤ 0.05 vs. placebo + sulfonylurea (-1.2, -0.6)	-1.3p ≤ 0.05 vs. placebo + sulfonylurea (-1.6, -1.0)
Fasting Plasma Glucose (mg/dL)	N=182	N=179	N=186
Baseline (mean)	236	247	239
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	6	-34	-52
Difference from placebo + sulfonylurea (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-39 p ≤ 0.05 vs. placebo + sulfonylurea (-52, -27)	-58 p ≤ 0.05 vs. placebo + sulfonylurea (-70, -46)

In the second trial, 702 patients were randomized to receive 30 mg or 45 mg of pioglitazone hydrochloride once daily for 24 weeks in addition to their current sulfonylurea regimen. The mean reduction from baseline at Week 24 in HbA1c was 1.6% for the 30 mg dose and 1.7% for the 45 mg dose (see Table 21). The mean reduction from baseline at Week 24 in FPG was 52 mg/dL for the 30 mg dose and 56 mg/dL for the 45 mg dose.

The therapeutic effect of pioglitazone hydrochloride in combination with sulfonylurea was observed in patients regardless of the sulfonylurea dose.

Table 21. Glycemic Parameters in a 24-Week Add-on to Sulfonylurea Trial
 

		Pioglitazone Hydrochloride          30 mg + Sulfonylurea	Pioglitazone Hydrochloride              45 mg + Sulfonylurea
Total Population
HbA1c (%)		N=340	N=332
Baseline (mean)		9.8	9.9
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)		-1.6	-1.7
Difference from 30 mg daily pioglitazone hydrochloride + sulfonylurea (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) (95% CI)			-0.1 (-0.4, 0.1)
Fasting Plasma Glucose (mg/dL)		N=338	N=329
Baseline (mean)		214	217
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)		-52	-56
Difference from 30 mg daily pioglitazone hydrochloride + sulfonylurea (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) (95% CI)			-5 (-12, 3)
95% CI = 95% confidence interval

Add-on to Metformin Trials:
Two clinical trials were conducted with pioglitazone hydrochloride in combination with metformin. Both trials included patients with type 2 diabetes on any dose of metformin, either alone or in combination with another antidiabetic agent. All other antidiabetic agents were withdrawn at least 3 weeks prior to starting study treatment.

In the first trial, 328 patients were randomized to receive either 30 mg of pioglitazone hydrochloride or placebo once daily for 16 weeks in addition to their current metformin regimen. Treatment with pioglitazone hydrochloride as add-on to metformin produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo add-on to metformin (see Table 22).

Table 22. Glycemic Parameters in a 16-Week Placebo-Controlled, Add-on to Metformin Trial

	Placebo + Metformin	Pioglitazone Hydrochloride 30 mg + Metformin
Total Population
HbA1c (%)	N=153	N=161
Baseline (mean)	9.8	9.9
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	0.2	-0.6
Difference from placebo + metformin(adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-0.8 p ≤ 0.05 vs. placebo + metformin (-1.2, -0.5)
Fasting Plasma Glucose (mg/dL)	N=157	N=165
Baseline (mean)	260	254
Change from baseline  (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-5	-43
Difference from placebo + metformin(adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-38p ≤ 0.05 vs. placebo + metformin (-49, -26)

In the second trial, 827 patients were randomized to receive either 30 mg or 45 mg of pioglitazone hydrochloride once daily for 24 weeks in addition to their current metformin regimen. The mean reduction from baseline at Week 24 in HbA1c was 0.8% for the 30 mg dose and 1.0% for the 45 mg dose (see Table 23). The mean reduction from baseline at Week 24 in FPG was 38 mg/dL for the 30 mg dose and 51 mg/dL for the 45 mg dose.

Table 23. Glycemic Parameters in a 24-Week Add-on to Metformin Study

	Pioglitazone Hydrochloride  30 mg + Metformin	Pioglitazone Hydrochloride  45 mg + Metformin
Total Population
HbA1C (%)	N=400	N=398
Baseline (mean)	9.9	9.8
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-0.8	-1.0
Difference from 30 mg daily pioglitazone hydrochloride + Metformin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)(95% CI)		-0.2 (-0.5, 0.1)
Fasting Plasma Glucose (mg/dL)	N=398	N=399
Baseline (mean)	233	232
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-38	-51
Difference from 30 mg daily pioglitazone hydrochloride + Metformin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) (95% CI)		-12p ≤ 0.05 vs. 30 mg daily pioglitazone hydrochloride + metformin (-21, -4)
95% CI = 95% confidence interval

The therapeutic effect of pioglitazone hydrochloride in combination with metformin was observed in patients regardless of the metformin dose.

Add-on to Insulin Trials:
Two clinical trials were conducted with pioglitazone hydrochloride in combination with insulin. Both trials included patients with type 2 diabetes on insulin, either alone or in combination with another antidiabetic agent. All other antidiabetic agents were withdrawn prior to starting study treatment. In the first trial, 566 patients were randomized to receive either 15 mg or 30 mg of pioglitazone hydrochloride or placebo once daily for 16 weeks in addition to their insulin regimen. Treatment with pioglitazone hydrochloride as add-on to insulin produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo add-on to insulin (see Table 24). The mean daily insulin dose at baseline in each treatment group was approximately 70 units. The majority of patients (75% overall, 86% treated with placebo, 77% treated with pioglitazone hydrochloride 15 mg, and 61% treated with pioglitazone hydrochloride 30 mg) had no change in their daily insulin dose from baseline to the final study visit. The mean change from baseline in daily dose of insulin (including patients with no insulin dose modifications) was -3 units in the patients treated with pioglitazone hydrochloride 15 mg, -8 units in the patients treated with pioglitazone hydrochloride 30 mg, and -1 unit in patients treated with placebo.

Table 24. Glycemic Parameters in a 16-Week Placebo-Controlled, Add-on to Insulin Trial

	Placebo + Insulin	Pioglitazone Hydrochloride            15 mg + Insulin	Pioglitazone Hydrochloride                      30 mg + Insulin
Total Population A1C (%)
HbA1C (%)	N=177	N=177	N=185
Baseline (mean)	9.8	9.8	9.8
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-0.3	-1.0	-1.3
Difference from placebo + Insulin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-0.7p ≤ 0.05 vs. placebo + insulin (-1.0, -0.5)	-1.0 p ≤ 0.05 vs. placebo + insulin (-1.3, -0.7)
Fasting Plasma Glucose (mg/dL)	N=179	N=183	N=184
Baseline (mean)	221	222	229
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	1	-35	-48
Difference from placebo + Insulin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) 95% Confidence Interval		-35 p ≤ 0.05 vs. placebo + insulin (-51, -19)	-49 p ≤ 0.05 vs. placebo + insulin (-65, -33)

In the second trial, 690 patients receiving a median of 60 units per day of insulin were randomized to receive either 30 mg or 45 mg of pioglitazone hydrochloride once daily for 24 weeks in addition to their current insulin regimen. The mean reduction from baseline at Week 24 in HbA1c was 1.2% for the 30 mg dose and 1.5% for the 45 mg dose. The mean reduction from baseline at Week 24 in FPG was 32 mg/dL for the 30 mg dose and 46 mg/dL for the 45 mg dose (see Table 25). The mean daily insulin dose at baseline in both treatment groups was approximately 70 units. The majority of patients (55% overall, 58% treated with pioglitazone hydrochloride 30 mg, and 52% treated with pioglitazone hydrochloride 45 mg) had no change in their daily insulin dose from baseline to the final study visit. The mean change from baseline in daily dose of insulin (including patients with no insulin dose modifications) was -5 units in the patients treated with pioglitazone hydrochloride 30 mg and -8 units in the patients treated with pioglitazone hydrochloride 45 mg.

The therapeutic effect of pioglitazone hydrochloride in combination with insulin was observed in patients regardless of the insulin dose.

Table 25. Glycemic Parameters in a 24-Week Add-on to Insulin Trial

	Pioglitazone Hydrochloride  30 mg + Insulin	Pioglitazone Hydrochloride 45 mg   + Insulin
Total Population
HbA1c (%)	N=328	N=328
Baseline (mean)	9.9	9.7
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-1.2	-1.5
Difference from 30 mg daily Pioglitazone hydrochloride + Insulin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) (95% CI)		-0.3 p ≤ 0.05 vs. 30 gm daily pioglitazone hydrochloride + insulin (-0.5, -0.1)
Fasting Plasma Glucose (mg/dL)	N=325	N=327
Baseline (mean)	202	199
Change from baseline (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction)	-32	-46
Difference from 30 mg daily  Pioglitazone hydrochloride + Insulin (adjusted meanAdjusted for baseline, pooled center, and pooled center by treatment interaction) (95% CI)		-14 p ≤ 0.05 vs. 30 gm daily pioglitazone hydrochloride + insulin (-25, -3)

16 HOW SUPPLIED/STORAGE AND HANDLING

Pioglitazone hydrochloride USP is available in 15 mg, 30 mg, and 45 mg tablets as follows:

15 mg tablet: White to off white, circular, flat face, bevelled edge, uncoated tablet debossed with "ML 86" on one side and plain on the other side available in:

NDC  33342-054-07 Bottles of 30
NDC  33342-054-10 Bottles of 90
NDC  33342-054-15 Bottles of 500

NDC 33342-054-12 Unit dose blister pack (10 x 10's)

30 mg tablet: White to off white, circular, flat face, bevelled edge, uncoated tablet debossed with "ML 87" on one side and plain on the other side available in:

NDC 33342-055-07 Bottles of 30
NDC 33342-055-10 Bottles of 90
NDC 33342-055-15 Bottles of 500

NDC 33342-055-12 Unit dose blister pack (10 x 10's)

45 mg tablet: White to off white, circular, flat face, bevelled edge, uncoated tablet debossed with "ML 91" on one side and plain on the other side available in:

NDC 33342-056-07 Bottles of 30
NDC 33342-056-10 Bottles of 90
NDC 33342-056-15 Bottles of 500

NDC 33342-056-12 Unit dose blister pack (10 x 10's)

Storage: Store at 20 - 25°C (68 - 77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Keep container tightly closed, and protect from light, moisture and humidity.

17 PATIENT COUNSELING INFORMATION

See FDA-Approved Patient Labeling (Medication Guide).

•It is important to instruct patients to adhere to dietary instructions and to have blood glucose and glycosylated hemoglobin tested regularly. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and patients should be reminded to seek medical advice promptly.
•Patients who experience an unusually rapid increase in weight or edema or who develop shortness of breath or other symptoms of heart failure while on pioglitazone tablets should immediately report these symptoms to a physician.
•Tell patients to promptly stop taking pioglitazone tablets and seek immediate medical advice if there is unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or dark urine as these symptoms may be due to hepatotoxicity.
•Tell patients to promptly report any sign of macroscopic hematuria or other symptoms such as dysuria or urinary urgency that develop or increase during treatment as these may be due to bladder cancer.
•Tell patients to take pioglitazone tablets once daily. Pioglitazone tablets can be taken with or without meals. If a dose is missed on one day, the dose should not be doubled the following day.
•When using combination therapy with insulin or other antidiabetic medications, the risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and their family members.
•Inform patients that therapy with pioglitazone tablets, like other thiazolidinediones, may result in ovulation in some premenopausal anovulatory women. As a result, these patients may be at an increased risk for pregnancy while taking pioglitazone tablets. Therefore, adequate contraception should be recommended for all premenopausal women who are prescribed pioglitazone tablets.

Manufactured for:

Macleods Pharma USA Inc.

Plainsboro, NJ 08536

Manufactured by:

Macleods Pharmaceutical Ltd.

Baddi, Himachal Pradesh, India.

Licensed – United States Patents Nos. 5,965,584; 6,150,383; 6,150,384; 6,166,042; 6,166,043; 6,172,090; 6,211,205; 6,271,243; 6,329,404, and 6,303,640.

Revised: January 2014

MEDICATION GUIDE

Pioglitazone Tablets USP

Read this Medication Guide carefully before you start taking pioglitazone tablets and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about pioglitazone tablets, ask your doctor or pharmacist.

What is the most important information I should know about pioglitazone tablets?
Pioglitazone tablets can cause serious side effects, including new or worse heart failure.

•Pioglitazone tablets can cause your body to keep extra fluid (fluid retention), which leads to swelling (edema) and weight gain. Extra body fluid can make some heart problems worse or lead to heart failure. Heart failure means your heart does not pump blood well enough
•Do not take pioglitazone tablets if you have severe heart failure
If you have heart failure with symptoms (such as shortness of breath or swelling), even if these symptoms are not severe, pioglitazone tablets may not be right for you

Call your doctor right away if you have any of the following:

•swelling or fluid retention, especially in the ankles or legs
•shortness of breath or trouble breathing, especially when you lie down
•an unusually fast increase in weight
•unusual tiredness
Pioglitazone tablets can have other serious side effects. See "What are the possible side effects of pioglitazone tablets?"

What is pioglitazone tablet?

Pioglitazone tablets are a prescription medicine used with diet and exercise to improve blood sugar (glucose) control in adults with type 2 diabetes. Pioglitazone tablets are a diabetes medicine called pioglitazone hydrochloride that may be taken alone or with other diabetes medicines.
It is not known if pioglitazone hydrochloride is safe and effective in children under the age of 18.
Pioglitazone tablet is not recommended for use in children.
Pioglitazone tablet is not for people with type 1 diabetes.
Pioglitazone tablet is not for people with diabetic ketoacidosis (increased ketones in your blood or urine).

Who should not take pioglitazone tablets?

See "What is the most important information I should know about pioglitazone tablets?"

Do not take pioglitazone tablets if you:

•have severe heart failure
•are allergic to any of the ingredients in pioglitazone tablets. See the end of this Medication Guide for a complete list of ingredients in pioglitazone tablets
Talk to your doctor before taking pioglitazone tablets if you have either of these conditions.

What should I tell my doctor before taking pioglitazone tablets?

Before you take starting pioglitazone tablets, tell your doctor if you:

• have heart failure
• have type 1 ("juvenile") diabetes or had diabetic ketoacidosis
• have a type of diabetic eye disease that causes swelling in the back of the eye (macular edema)
• have liver problems
• have or have had cancer of the bladder
• are pregnant or plan to become pregnant. It is not known if pioglitazone tablets will harm your unborn baby. Talk to your doctor if you are pregnant or plan to become pregnant about the best way to control your blood glucose levels while pregnant
• are a premenopausal woman (before the "change of life") who does not have periods regularly or at all. Pioglitazone tablets may increase your chance of becoming pregnant. Talk to your doctor about birth control choices while taking pioglitazone tablets. Tell your doctor right away if you become pregnant while taking pioglitazone tablets
• are breastfeeding or plan to breastfeed. It is not known if pioglitazone  passes into your milk and if it can harm your baby. You should not take pioglitazone tablets if you breastfeed your baby. Talk to your doctor about the best way to control your blood glucose levels while breastfeeding.

Tell your doctor about all the medicines you take including prescription and over the counter medicines, vitamins, and herbal supplement.
Pioglitazone tablets and some of your other medicines can affect each other. You may need to have your dose of pioglitazone tablets or certain other medicines changed.
Know the medicines you take. Keep a list of your medicines and show it to your doctor and pharmacist before you start a new medicine. They will tell you if it is okay to take pioglitazone tablets with other medicines.

How should I take pioglitazone tablets?

•Take pioglitazone tablets exactly as your doctor tells you to take it
•Your doctor may change your dose of pioglitazone tablets. Do not change your pioglitazone tablets dose unless your doctor tells you to
• Pioglitazone tablets may be prescribed alone or with other diabetes medicines. This will depend on how well your blood sugar is controlled
•Take pioglitazone tablets one time each day, with or without food
•If you miss a dose of pioglitazone tablets, take your next dose as prescribed unless your doctor tells you differently. Do not take two doses at one time the next day
•If you take too much pioglitazone tablets, call your doctor or go to the nearest hospital emergency room right away
•If your body is under stress such as from a fever, infection, accident, or surgery the dose of your diabetes medicines may need to be changed. Call your doctor right away
•Stay on your diet and exercise programs and test your blood sugar regularly while taking pioglitazone tablets
•Your doctor should do certain blood tests before you start and while you take pioglitazone tablets
•Your doctor should also do hemoglobin A1C testing to check how well your blood sugar is controlled with pioglitazone tablets
•Your doctor should check your eyes regularly while you take pioglitazone tablets.

What are the possible side effects of pioglitazone tablets?
Pioglitazone tablets may cause serious side effects including:
• See "What is the most important information I should know about pioglitazone tablets."

    • low blood sugar (hypoglycemia). This can happen if you skip meals, if you also use another medicine that lowers blood
           sugar, or if you have certain medical problems. Lightheadedness, dizziness, shakiness, or hunger may happen if your blood sugar is
           too low. Call your doctor if low blood sugar levels are a problem for you
• liver problems. Call your doctor right away if you have:

      o nausea or vomiting
      o stomach pain
      o unusual or unexplained tiredness
      o loss of appetite
      o dark urine
      o yellowing of your skin or the whites of your eyes

    • bladder cancer. There may be an increased chance of having bladder cancer when you take pioglitazone hydrochloride. You
           should not take pioglitazone hydrochloride if you are receiving treatment for bladder cancer. Tell your doctor right away if you have 
           any of the following symptoms of bladder cancer:
               o blood or a red color in your urine
               o an increased need to urinate
               o pain while you urinate
     • broken bones (fractures). Usually in the hand, upper arm, or foot in women. Talk to your doctor for advice on how to keep
            your  bones healthy.
• diabetic eye disease with swelling in the back of the eye (macular edema). Tell your doctor right away if you have any 
      changes in your vision. Your doctor should check your eyes regularly
• release of an egg from an ovary in a woman (ovulation) leading to pregnancy. Ovulation may happen when      
      premenopausal women who do not have regular monthly periods take pioglitazone tablets. This can increase your chance of getting
      pregnant

The most common side effects of pioglitazone tablets include:
• cold-like symptoms (upper respiratory tract infection)
• headache
• sinus infection
• muscle pain
• sore throat

Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all the side effects of pioglitazone tablets. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store pioglitazone tablets?   

•Store pioglitazone tablets at 20 - 25°C (68 - 77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room  
     Temperature]. Keep pioglitazone tablets in the original container and protect from light
•Keep the pioglitazone tablets bottle tightly closed and  keep tablets dry
•Keep pioglitazone tablets and all medicines out of the reach of children
 

General information about the safe and effective use of pioglitazone tablets

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use pioglitazone tablets for a condition for which it was not prescribed. Do not give pioglitazone tablets to other people, even if they have the same symptoms you have. It may harm them.

This Medication Guide summarizes the most important information about pioglitazone tablets. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about pioglitazone tablets that is written for healthcare professionals.

For more information, call 1-888-943-3210.

What are the ingredients in pioglitazone tablets? 
    

Active Ingredient: pioglitazone hydrochloride, USP

Inactive Ingredients: lactose monohydrate, hydroxypropylcellulose, carboxymethylcellulose calcium, and magnesium stearate.

This Medication Guide has been approved by the U.S. Food and Drug Administration

Manufactured for:

Macleods Pharma USA Inc.

Plainsboro, NJ 08536

Manufactured by:

Macleods Pharmaceutical Ltd.

Baddi, Himachal Pradesh, India.

Licensed – United States Patents Nos. 5,965,584; 6,150,383; 6,150,384; 6,166,042; 6,166,043; 6,172,090; 6,211,205; 6,271,243; 6,329,404, and 6,303,640.

Revised: January 2014

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL

Principal Display Panel

NDC 33342-054-07
Pioglitazone Tablets USP
15 mg
Rx only  

30 Tablets

Principal Display Panel

NDC 33342-055-07
Pioglitazone Tablets USP
30 mg
Rx only  

30 Tablets

Principal Display Panel

NDC 33342-056-07
Pioglitazone Tablets USP
45 mg
Rx only  

30 Tablets