Should You Hold Empagliflozin (Jardiance) During an Infection?
Yes, you should hold empagliflozin during acute infections, particularly when patients are at risk for volume depletion, have poor oral intake, or are experiencing severe illness. 1
Key Clinical Guidance
The 2021 Lancet guideline on hospital diabetes management explicitly recommends discontinuing SGLT2 inhibitors during acute illness 1. The 2025 ADA Standards of Care reinforce this by stating empagliflozin should be discontinued during critical illness or prolonged fasting 2.
When to Hold Empagliflozin
Mandatory discontinuation scenarios:
- Acute infections with volume depletion risk (fever, vomiting, diarrhea, poor oral intake)
- Critical illness or sepsis - even though animal data suggests potential anti-inflammatory effects 3, human safety data is insufficient
- Scheduled surgery - discontinue 3-4 days before procedures 2
- Diabetic ketoacidosis (DKA) risk - particularly with insulin deficiency, even if euglycemic 2
Infection-Specific Risks
Genitourinary Infections
The primary infection concern with empagliflozin is increased risk of genital mycotic infections due to glycosuria 2. More serious but rare complications include:
- Fournier's gangrene (necrotizing fasciitis of the perineum) - rare but requires prompt recognition and immediate drug discontinuation 2, 4, 5
- Urinary tract infections - particularly in women and catheter users, though recent data shows no significant increase in catheterized patients 6
Volume Depletion During Infection
Empagliflozin causes osmotic diuresis, which compounds volume loss from:
- Fever and increased insensible losses
- Vomiting or diarrhea
- Reduced oral intake during illness
This creates risk for intravascular volume depletion, hypotension, and acute kidney injury 2.
Clinical Algorithm for Decision-Making
Hold empagliflozin if ANY of the following:
- Fever >38.5°C with reduced oral intake
- Vomiting or diarrhea causing dehydration
- Signs of volume depletion (orthostatic hypotension, tachycardia, decreased urine output)
- Acute kidney injury or rising creatinine
- Genital or perineal infection (especially with pain, swelling, or systemic symptoms)
- Sepsis or systemic inflammatory response
May continue if ALL of the following:
- Mild, localized infection (e.g., uncomplicated upper respiratory infection)
- Normal oral intake maintained
- Hemodynamically stable
- No signs of volume depletion
- Normal kidney function
When to Restart
Resume empagliflozin only after:
- Infection resolved or controlled
- Normal oral intake restored
- Volume status normalized
- Kidney function stable or returned to baseline
- Patient no longer at risk for DKA
Critical Pitfalls to Avoid
Euglycemic DKA: The most dangerous complication - patients can develop ketoacidosis with normal or only mildly elevated glucose levels 2. During infections with poor intake, insulin deficiency increases while empagliflozin continues glucose excretion, creating perfect conditions for DKA.
Delayed recognition of Fournier's gangrene: Any genital pain, swelling, or erythema in a patient on empagliflozin requires immediate evaluation and drug discontinuation 4, 5. This is a surgical emergency.
Continuing during dehydration: The combination of infection-related volume loss and SGLT2 inhibitor-induced diuresis significantly increases acute kidney injury risk 2.
Special Populations
Immunocompromised patients: Exercise extra caution - case reports document severe infections including Fournier's gangrene in HIV-positive patients on empagliflozin 5.
Elderly patients: Higher baseline risk for volume depletion and infection complications - lower threshold for discontinuation.
Catheterized patients: Recent data suggests no significant increase in UTI risk 6, but maintain vigilance for symptomatic infections requiring treatment.