How to manage SGLT2 (Sodium-Glucose Linked Transporter 2) inhibitors in a patient with scrotal cellulitis?

From the Guidelines

For a patient with scrotal cellulitis who is taking an SGLT2 inhibitor, the medication should be temporarily discontinued until the infection resolves completely, as indicated by the need to hold SGLT2i during illness, particularly when there's a risk of worsening infection due to the medication's effect on glucose excretion 1. When managing a patient with scrotal cellulitis who is on an SGLT2 inhibitor, it's crucial to prioritize the treatment of the infection to prevent complications such as necrotizing fasciitis of the perineum (Fournier's gangrene). The patient should receive appropriate antibiotic therapy, and alternative diabetes management should be implemented, typically with insulin therapy if needed for glycemic control.

Key Considerations:

• SGLT2 inhibitors increase the risk of genital mycotic infections due to the glucose-rich environment they create in the genital region 1.
• The risk of severe infections, such as Fournier gangrene, although rare, necessitates caution and close monitoring 1.
• Counseling on genital hygiene is recommended for patients on SGLT2 inhibitors to reduce the risk of infections 1.
• Holding the SGLT2 inhibitor during the illness and restarting it only after complete resolution of the infection is a prudent approach to manage the risk of infection worsening due to the medication 1.

Management Approach:

• Temporarily discontinue the SGLT2 inhibitor upon diagnosis of scrotal cellulitis.
• Implement alternative diabetes management, typically with insulin therapy, to maintain glycemic control.
• Initiate appropriate antibiotic therapy for the cellulitis, considering coverage for both gram-positive and gram-negative organisms.
• Monitor the patient closely for signs of infection progression and educate them on maintaining good perineal hygiene and recognizing signs of worsening infection that require immediate medical attention.
• Restart the SGLT2 inhibitor cautiously only after the infection has completely resolved, typically 1-2 weeks after all symptoms have resolved.

From the Research

Management of SGLT2 Inhibitors in Patients with Scrotal Cellulitis

• The use of SGLT2 inhibitors has been associated with an increased risk of genital infections, including scrotal cellulitis, due to increased glycosuria 2, 3, 4.
• In patients with scrotal cellulitis, it is recommended to cease SGLT2 inhibitors to prevent progression to more severe infections, such as Fournier's gangrene 2.
• The risk of genital infections with SGLT2 inhibitors is higher in patients with certain risk factors, including female sex, history of genital infection, and immunosuppressed states 4.
• In some cases, SGLT2 inhibitors can be continued with the addition of topical treatments, but in severe cases, discontinuation of the drug may be necessary 5.
• Prescribers should be aware of the potential adverse genitourinary infectious outcomes associated with SGLT2 inhibitors and use caution when initiating or continuing these medications in patients with scrotal cellulitis or other genitourinary infections 6.

Risk Factors for Genital Infections with SGLT2 Inhibitors

• Female sex 4
• History of genital infection 4
• Immunocompromised states 2
• Obesity 2
• Smoking 2
• Alcohol abuse 2
• End-stage renal or liver failure 2

Treatment of Genital Infections with SGLT2 Inhibitors

• Topical treatments, such as anti-fungal creams 3, 5
• Systemic antifungals, such as fluconazole 5
• Discontinuation of SGLT2 inhibitors in severe cases 2, 5