Background and objectives: Previous studies have reported the protective effect of pioglitazone on dementia in type 2 diabetic mellitus (DM) patients. Recent studies have shown that pioglitazone also lowers the risk of primary and recurrent stroke. Understanding the characteristics of patients particularly associated with the benefits of pioglitazone would facilitate its personalized use by specifying subpopulations during routine clinical care. The aim of this study was to examine the effects of pioglitazone use on dementia in consideration of stroke occurrence.
Methods: Using nationwide longitudinal data of DM patients from the Korean National Health Insurance Service DM cohort (2002–2017), we investigated the association of pioglitazone use with incident dementia in patients with new-onset type 2 DM. The heterogeneity of the treatment effect was examined using exploratory analyses. Using a multi-state model, we assessed the extent to which incident stroke affects the association between pioglitazone use and dementia.
Results: Pioglitazone use was associated with a reduced risk of dementia, compared with non-use (adjusted hazard ratio (HR) = 0.84, 95% CI, 0.75-0.95); the risk reduction in dementia was greater among patients with a history of ischemic heart disease or stroke before DM onset (adjusted HR = 0.46, 95% CI, 0.24-0.90, adjust HR = 0.57, 95% CI, 0.38-0.86, respectively). The incidence of stroke was also reduced by pioglitazone use (adjusted HR = 0.81, 95% CI, 0.66-1.00). However, when the stroke developed during the observation period of pioglitazone use, such lowered risk of dementia was not observed (adjusted HR = 1.27, 95% CI, 0.80-2.04).
Discussion: Pioglitazone use is associated with a lower risk of dementia in DM patients, particularly in those with a history of stroke or ischemic heart disease, suggesting the possibility of applying a personalized approach when choosing pioglitazone to suppress dementia in DM patients