In a related editorial, the authors note that although this study aimed to provide recommendations for patients with type 2 diabetes, only half of all patients had diabetes at enrollment. Moreover, it did not include an analysis that compared outcomes among diabetic and prediabetic participants. Thus, whether efficacy differs according to the presence of prediabetes or diabetes remains uncertain.
The authors also note that “Whether physicians should include pioglitazone in the therapeutic arsenal for diabetic patients with nonalcoholic steatohepatitis (NASH) is unclear on the basis of this RCT…We believe that physicians should consider adding pioglitazone to their toolboxes when facing patients with NASH and diabetes, but the primary obstacle to the widespread use of pioglitazone remains its safety profile. Thus, treatment should be considered for patients at the greatest risk (those with NASH and fibrosis) and should be balanced against the common risk for weight gain and the uncommon risks for fracture and heart failure”.