How to manage a patient with ketonuria, hypoglycemia (low blood glucose), and yeast in urine, who is taking Jardiance (empagliflozin)?

From the Guidelines

A patient with ketonuria, hypoglycemia, and yeast in urine who is taking Jardiance (empagliflozin) should immediately discontinue the medication and seek medical attention. Jardiance should be temporarily stopped as it can worsen both ketonuria and yeast infections while potentially contributing to hypoglycemia in this clinical scenario. The patient needs prompt evaluation for euglycemic diabetic ketoacidosis (euDKA), a serious complication of SGLT2 inhibitors like Jardiance, as suggested by the presence of ketonuria and hypoglycemia 1. Treatment typically includes IV fluids, insulin therapy, and glucose supplementation to address the metabolic derangements, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances 1. The urinary yeast infection should be treated with an appropriate antifungal medication such as fluconazole 150mg as a single oral dose, considering potential interactions with other medications like sulfonylureas 1. Before restarting Jardiance, the underlying causes of hypoglycemia must be identified and addressed, which may include adjusting other diabetes medications, reviewing carbohydrate intake, or addressing other medical conditions, and following sick day rules to prevent further complications 1. SGLT2 inhibitors like Jardiance work by preventing glucose reabsorption in the kidneys, which increases glucose excretion in urine, creating an environment favorable for yeast growth and potentially promoting ketone production, especially during periods of low carbohydrate intake or illness 1. The combination of these symptoms suggests a potentially dangerous metabolic state that requires immediate medical intervention to prevent morbidity, mortality, and to improve quality of life.

From the FDA Drug Label

Instruct patients to check ketones (when possible) if symptoms consistent with ketoacidosis occur even if blood glucose is not elevated. If symptoms of ketoacidosis (including nausea, vomiting, abdominal pain, tiredness, and labored breathing) occur, instruct patients to discontinue JARDIANCE and seek medical advice immediately [see Warnings and Precautions (5. 2)]. Inform female patients that vaginal yeast infections may occur and provide them with information on the signs and symptoms of vaginal yeast infections. Yeast infection of the penis (balanitis or balanoposthitis). Men who take JARDIANCE may get a yeast infection of the skin around the penis

The patient has ketonuria, hypoglycemia (low blood glucose), and yeast in urine while taking Jardiance (empagliflozin).

• Ketonuria and hypoglycemia may indicate ketoacidosis, a serious life-threatening condition.
• Yeast in urine may be a sign of a urinary tract infection or genital mycotic infection. Given the patient's symptoms, it is recommended to:
• Discontinue JARDIANCE and seek medical advice immediately if symptoms of ketoacidosis occur.
• Monitor blood glucose and ketone levels closely.
• Treat the yeast infection with an antifungal medication.
• Seek medical attention if the patient experiences any symptoms of a urinary tract infection or genital mycotic infection. 2

From the Research

Patient Presentation

• The patient has ketonuria, indicating the presence of ketones in the urine, which is a sign of diabetic ketoacidosis (DKA) 3, 4, 5, 6, 7.
• The patient's blood glucose level is 57, which is considered hypoglycemic, and the capillary blood sugar is 96, which is slightly elevated.
• The presence of yeast in the urine may indicate a urinary tract infection, which can be a precipitating factor for DKA 4, 5, 7.
• The patient is taking Jardiance (empagliflozin), a sodium-glucose cotransporter-2 (SGLT2) inhibitor, which can increase the risk of DKA and euglycemic DKA 4, 5, 6.

Management Considerations

• The patient's hypoglycemia should be addressed promptly with glucose administration to prevent further complications.
• The presence of ketonuria and yeast in the urine suggests that the patient may have DKA, which requires aggressive management with intravenous fluids, insulin therapy, and electrolyte replacement 3, 4, 5, 7.
• The use of SGLT2 inhibitors, such as Jardiance, may need to be re-evaluated in the context of the patient's DKA diagnosis 4, 5, 6.
• The patient's underlying precipitating factors, such as the urinary tract infection, should be identified and treated promptly to prevent further episodes of DKA 4, 5, 7.

Diagnostic Evaluation

• Laboratory tests, such as venous blood gas, serum pH, bicarbonate, and ketones, should be performed to confirm the diagnosis of DKA and to monitor the patient's response to treatment 4, 6, 7.
• A complete blood cell count with differential, A1C, and electrocardiography should also be performed to evaluate for any underlying conditions that may be contributing to the patient's DKA 4.
• Urinalysis and blood and urine cultures should be performed to evaluate for any underlying infections that may be contributing to the patient's DKA 4, 7.