Pioglitazone: An Ongoing Misery in the Developing Countries to Which I cant be Pragmatic!

Editorial

In 2014, I've published an article warning against the widespread usage of pioglitazone in the developing countries though it has been banned or heavily restricted in all developed countries due to its proved causation with an increased incidence of bladder carcinoma [1]. The widespread usage of pioglitazone in these unfortunate countries is associated with widespread ignorance in the medical community as well as widespread greed in the pharmaceutical industry and stakeholders. Unfortunately, in 2018, nothing has been changed on the ground, at least in my country; Egypt though sincere efforts to convince officials to do their work have been made though in vain. One official has carelessly answered my request at an international conference saying: "Be pragmatic. We've sent dear dr letters to raise the awareness of the prescribing doctors" and even though every single doctor I've asked denied receiving any message regarding this highly important topic, the message remains the same: "Be pragmatic" I'm really sorry that I can't be pragmatic especially when reading more and more evidence linking pioglitazone to bladder cancer; Garry et al. in 2018 have concluded: "Pioglitazone was associated with an elevated risk of bladder cancer compared with DPP-4s and sulfonylureas. The elevated risk emerged within the first 2 years of treatment and was attenuated after discontinuing" Tang et al. [2] after confirming that current evidence suggests that pioglitazone may increase the risk of bladder cancer, possibly in a dose- and time-dependent manner have also pointed to the miserable fact that this association differs with the source of funding (sponsored by industry or not) [3] Another met analysis confirmed that pioglitazone increased the risk for bladder cancer could be found in European population, especially in patients who undergo treatment with pioglitazone for longer durations (>12 months) or are administrated a larger cumulative dose (>28,000 mg) and tried to investigate the causes for conflicting results [4]. I'm really sorry that I can't be pragmatic accepting that there's no conflict of interest when an author calls for a "resurrection" in the usage of pioglitazone and we notice at the end of his article that he was an expert witness for Takeda pharmacetuicals! [5] I can't be pragmatic when I read that "there's no evidence of an association between ever use of pioglitzone and risk of bladder cancer compared with never use" then to find the authors connected to several pharmaceutical companies including Takeda [6]. I can't be pragmatic while still noticing "millions of patients in developing countries where many conditions favor carcinogenicity; polluted air, water, food, smoking … etc. denied their ethical and medico-legal right to choose a possibly safer drug", denied their right to be equal in knowledge and choice with other human beings in developed countries. Finally, my call in 2014 to work hard and fast to ban pioglitazone further entrance to the developing countries remains unanswered today and I'd like to finish this editorial with a quote and call from another editorial that remains valid: "I don’t doubt the honesty of fellow colleagues, God forbids but I only admit the logic human suspicion that knowing that even the saints among us are tempted. Thus, humbly, I ask all scientists in the developed world to work together to obligate the FDA and all similar agencies to establish a new mechanism by which the large pharmaceutical companies become forced to fund “real” independent research center(s) not chosen by or related in any way to the pharmaceutical companies and their products; center(s) that will, on behalf of all the patients, honor the human suspicion and will design, perform and analyze all the post marketing drug safety studies and thus defending the noble human soul that seeks science and humanity more than stocks and shares" [1, 7].