Should a patient with Candida species and Candida glabrata vulvovaginitis stop taking an SGLT-2 (sodium-glucose cotransporter-2) inhibitor for diabetes and what treatment is recommended for vulvovaginitis?

Management of Candida glabrata Vulvovaginitis in a Diabetic Patient on SGLT-2 Inhibitor

The patient should temporarily discontinue the SGLT-2 inhibitor and be treated with topical intravaginal boric acid 600 mg daily for 14 days for Candida glabrata vulvovaginitis. 1

SGLT-2 Inhibitor Considerations

SGLT-2 inhibitors increase urinary glucose excretion, which creates an environment favorable for fungal growth. Research has demonstrated that:

• Patients taking canagliflozin (an SGLT-2 inhibitor) have significantly higher rates of vaginal Candida colonization (31% vs 14% for placebo/sitagliptin) 2
• SGLT-2 inhibitor use is associated with increased vulvovaginal adverse events (10% vs 3% for placebo/sitagliptin) 2
• Patients with positive Candida cultures at baseline have 9.1 times higher risk of developing vulvovaginal adverse events when taking SGLT-2 inhibitors 2

Given these findings, temporarily discontinuing the SGLT-2 inhibitor is recommended while treating the vulvovaginitis. This medication can be reconsidered after successful treatment and clearance of the infection.

Treatment Algorithm for Candida glabrata Vulvovaginitis

First-line treatment:

• Boric acid vaginal suppositories: 600 mg intravaginally daily for 14 days 1
  • This is the recommended treatment for C. glabrata vulvovaginitis that is unresponsive to oral azoles
  • Studies show significantly higher mycological cure rates with boric acid (72.4%) compared to fluconazole (33.3%) in diabetic women with C. glabrata infection 3

Alternative options (if boric acid is unavailable or not tolerated):

1. Nystatin intravaginal suppositories: 100,000 units daily for 14 days 1
2. Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Important considerations:

• Fluconazole and other oral azoles have poor efficacy against C. glabrata (only 28.6-33.3% cure rate) 3, 4
• C. glabrata is the predominant species (39-54%) in diabetic women with vulvovaginal candidiasis 4, 5
• Poor glycemic control increases risk of vulvovaginal candidiasis and treatment failure 6, 5

Follow-up and Prevention

1. Glycemic control:

   • Optimize diabetes management with alternative medications while SGLT-2 inhibitor is discontinued
   • Consider HbA1c testing, as higher levels correlate with increased risk of vulvovaginal candidiasis 5

2. Follow-up:

   • Return for evaluation if symptoms persist after completing treatment 1
   • Consider test-of-cure culture in diabetic patients with C. glabrata due to higher treatment failure rates

3. Prevention:

   • Maintain optimal glycemic control
   • Consider prophylaxis if recurrent infections develop after SGLT-2 inhibitor is restarted

Special Considerations

• If the patient absolutely requires the SGLT-2 inhibitor for glycemic control, consider maintenance antifungal therapy (fluconazole 150 mg weekly) after successful treatment 1
• Treatment of sexual partners is generally not recommended unless they are symptomatic 1
• C. glabrata infections are particularly challenging in diabetic patients and may require longer treatment courses or combination therapy

The combination of discontinuing the SGLT-2 inhibitor and using boric acid vaginal suppositories provides the best chance for complete resolution of C. glabrata vulvovaginitis in this diabetic patient.