From the Guidelines
Trijardy (empagliflozin, linagliptin, metformin) carries a significant risk of genital fungal infections, particularly in women, due to the SGLT2 inhibitor component empagliflozin, and this risk can be mitigated with good hygiene and managed with topical or oral antifungal treatments as needed. The risk of genital mycotic infections is a known complication of SGLT2 inhibitors, with a meta-analysis of clinical trials reporting that these infections occurred in 6% of participants assigned to an SGLT2i, compared with 1% of those assigned to placebo 1. Women are at a higher risk than men, with symptoms including genital itching, redness, swelling, and unusual discharge.
Management and Prevention
Management typically involves:
- Topical antifungal treatments like clotrimazole or miconazole for mild cases, applied for 1-7 days depending on the product
- More severe or recurrent infections may require oral antifungal medications such as fluconazole 150 mg as a single dose To prevent these infections, patients should:
- Maintain good hygiene by washing the genital area daily with mild soap and water
- Wear loose cotton underwear
- Avoid prolonged wet swimwear
- Thoroughly dry the genital area after bathing Patients should not discontinue Trijardy if they develop a fungal infection unless advised by their healthcare provider, as these infections are typically manageable while continuing diabetes treatment 1. Patients with recurrent infections should discuss preventive strategies with their healthcare provider, which might include prophylactic antifungal medications.
Key Considerations
It is essential to counsel patients on genital hygiene to reduce the risk of genital mycotic infections when initiating SGLT2 inhibitors like empagliflozin in Trijardy 1. Monitoring for signs of volume depletion and adjusting background therapies as appropriate is also crucial when initiating an SGLT2i. The risk of hypoglycemia and diabetic ketoacidosis should be considered, especially in patients requiring insulin, and managed accordingly. Overall, the benefits of Trijardy in managing diabetes and reducing cardiovascular risk can be maintained while effectively managing the risk of genital fungal infections with proper hygiene, monitoring, and treatment.
From the Research
Risks of Fungal Infections with Trijardy
- Trijardy, a medication that combines empagliflozin, linagliptin, and metformin, may increase the risk of fungal infections due to the empagliflozin component, which is a sodium-glucose cotransporter 2 (SGLT2) inhibitor 2, 3, 4, 5, 6.
- The risk of genital fungal infections is higher in women and patients with a prior history of genital fungal infections 2.
- Fungal infections, including genital mycotic infections and urinary tract infections, have been reported in patients taking SGLT2 inhibitors, including empagliflozin 3, 4, 5, 6.
Management of Fungal Infections
- Patients taking Trijardy should be educated about the risk of fungal infections and the importance of practicing good hygiene to minimize this risk 4.
- Clinicians should be aware of the mechanism of action of SGLT2 inhibitors and the associated risk of infection, and assess patients for urogenital anatomical abnormalities before prescribing these medications 3.
- Treatment of fungal infections typically involves antifungal therapy, and in some cases, discontinuation of the SGLT2 inhibitor may be necessary 3, 6.
- Patients with complicated fungal infections, such as candidemia, may require prolonged courses of antifungal therapy and close monitoring 3.