Editor—The interesting drug point by Farley-Hills et al, on fatal liver failure associated with pioglitazone, is missing data.1 I hope that it will remind doctors to monitor liver function and not cause a scare similar to that which occurred with troglitazone.2
Farley-Hills, for example, did not mention a liver function test before treatment with pioglitazone was started or whether the profile of the liver functions test was monitored after that. The guidance from the National Institute for Clincial Excellence (NICE) and British National Formulary both recommended that, as do the manufacturers.3 No details about glycaemic control were given before blaming the patient's diabetes for his severe liver failure. Was there any reaction to gliclazide before, such as an abnormal liver function test, because gliclazide has been reported before to cause liver derangement?
It seems from the patient's histopathology report that he had chronic liver disease accompanied by fibrosis. Either the clinician failed to follow the guidelines or the screening test for liver function is not robust enough to pick up such disorder and consequently avoid thiazolidinediones.
Competing interests: PA has given lectures that were sponsored by Takeda to primary care trusts.
References
- 1.Farley-Hills E, Sivasankar R, Martin M. Fatal liver failure associated with pioglitazone. BMJ 2004;329: 429. (21 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Isley WL. Hepatoxicity of thiozolidinediones. Expert Opin Drug Saf 2003;2(6): 581-6. [DOI] [PubMed] [Google Scholar]
- 3.National Institute for Clinical Excellence. Guidance on the use of glitazones for the treatment of type 2 diabetes. London: NICE, 2003. (Technology Appraisal 63.)