OBJECTIVE: To evaluate the association between pioglitazone use and bladder cancer risk in patients with type 2 diabetes. DESIGN: Retrospective cohort study using propensity score matched cohorts. SETTINGS: Healthcare databases from Finland, the Neherlands, Sweden, and the United Kingdom. Data comprised country specific datasets of linked records on prescriptions, hospitals, general practitioners, cancer, and deaths. PARTICIPANTS: Patients with type 2 diabetes who initiated pioglitazone (n=56 337)matched with patients with type 2 diabetes in the same country exposed to diabetes drug treatments other than pioglitazone (n=317 109). Two matched cohorts were created, using a 1:1 fixed ratio (nearest match cohort) and a 1:10 variable ratio (multiplematch cohort). Patients were matched on treatment history and propensity scores accounting for several variables associated with pioglitazone initiation. MAIN OUTCOME MEASURES: Hazard ratios and 95% confidence intervals were estimated by Cox’s proportional hazards model with adjustments for relevant confounders. To assess the robustness of the findings, several sensitivity and stratified analyses were performed. RESULTS: In the cohort exposed to pioglitazone treatment, 130 bladder cancers occurred overa mean follow-up time of 2.9 years. In the nearest match and multiple match cohorts not exposed to pioglitazone treatment, 153 and 970 bladder cancers were recorded, with a mean followup time of 2.8 and 2.9 years, respectively. With regards to bladder cancer risk, the adjusted hazard ratio for patients ever exposed versus never exposed to pioglitazone was 0.99 (95% confidence interval 0.75 to 1.30) and 1.00 (0.83 to 1.21) in the nearest and multiple match cohorts, respectively. Increasing duration of pioglitazone use and increasing cumulative dose were not associated with risk of bladder cancer (>48 months of pioglitazone use, adjusted hazard ratio 0.86 (0.44 to 1.66); >40 000 mg cumulative dose, 0.65 (0.33 to 1.26) in the nearest match cohort). CONCLUSIONS: This study shows no evidence of an association between ever use of pioglitzone and risk of bladder cancer compared with never use, which is consistent with results from other recent studies that also included a long follow-up period. TRIAL REGISTRATION: Registered to the European Union electronic register of post-authorisation studies (EU PAS register no EUPAS3626).