Is there still room for pioglitazone in contemporary type 2 diabetes management?

Recent real-world evidence comparing glucagon-like peptide-1 receptor agonists (GLP-1RA) with pioglitazone indicates broadly comparable cardiovascular and hepatic outcomes in individuals with type 2 diabetes, with a lower risk of heart failure among GLP-1RA users. These findings must be interpreted in the context of contemporary guidelines, which increasingly prioritize therapies with cardiometabolic benefits while restricting the role of pioglitazone to selected settings. Despite recognized adverse effects, pioglitazone retains clinical relevance due to its glycaemic efficacy, potential cardio-hepatic benefits, and low cost, particularly in health-care systems with limited access to newer agents. Rather than being interchangeable, pioglitazone and GLP-1RA occupy complementary positions within the current therapeutic landscape, underscoring the importance of individualized treatment selection.