What are the treatment options for genital mycotic infections caused by Jardiance (empagliflozin)?

Treatment of Genital Mycotic Infections Caused by Jardiance (Empagliflozin)

For genital mycotic infections caused by Jardiance (empagliflozin), the first-line treatment is either a single oral dose of fluconazole 150 mg or a short course of topical azole therapy for 1-7 days depending on the formulation. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Symptoms typically include pruritus, irritation, vaginal soreness, and white discharge
• Laboratory confirmation with wet-mount preparation showing yeast or pseudohyphae
• Normal vaginal pH (≤4.5)

Treatment Options

For Uncomplicated Infections (First Episode, Mild-to-Moderate)

Oral Therapy:

• Fluconazole 150 mg oral tablet, one tablet in single dose 2, 1
  • Achieves >90% response rate
  • Convenient single-dose administration
  • Contraindicated during pregnancy

Topical Therapy Options:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 2
• Clotrimazole 100 mg vaginal tablet for 7 days 2
• Clotrimazole 500 mg vaginal tablet, one tablet in single application 2
• Miconazole 2% cream 5g intravaginally for 7 days 2
• Miconazole 200 mg vaginal suppository, one suppository for 3 days 2
• Butoconazole 2% cream 5g intravaginally for 3 days 2
• Terconazole 0.4% cream 5g intravaginally for 7 days 2
• Terconazole 0.8% cream 5g intravaginally for 3 days 2
• Tioconazole 6.5% ointment 5g intravaginally in a single application 2

For Severe or Recurrent Infections

• Fluconazole 150 mg every 72 hours for 3 doses 1
• Topical azole therapy for 7-14 days 1
• For non-albicans species (e.g., C. glabrata), consider:
  • Boric acid or nystatin intravaginal suppositories 1
  • Longer duration of topical therapy 1

Special Considerations

For Pregnant Women

• Only use topical azole therapy 1
• Avoid oral fluconazole due to risk of spontaneous abortion and birth defects, especially in first trimester 1

For HIV-Positive Patients

• Same treatment regimens as HIV-negative patients 2

For Recurrent Infections (≥4 episodes in 12 months)

• Maintenance therapy with fluconazole 150 mg weekly for 6 months 1
• Note: 40-50% recurrence rate can be expected after stopping maintenance therapy 1

Prevention Strategies for SGLT2 Inhibitor Users

Since SGLT2 inhibitors like empagliflozin significantly increase the risk of genital mycotic infections (25.9% of patients experience at least one episode) 3, prevention is crucial:

1. Maintain proper genital hygiene
2. Ensure adequate hydration by drinking plenty of water 4
3. Educate patients about side effects and precautions (patients with knowledge of side effects have significantly lower infection rates) 3
4. Consider more frequent monitoring in high-risk patients:
   • Women (higher risk than men) 5
   • Patients with previous history of genital fungal infections 5
   • Patients with poorly controlled diabetes 6

Follow-Up

• Return visit is only necessary if symptoms persist or recur within 2 months 2
• If symptoms persist after using OTC preparations or recur within 2 months, medical care should be sought 2

Important Caveats

1. Do not treat asymptomatic colonization - 10-20% of women normally harbor Candida without symptoms 1
2. Partner treatment is not routinely recommended unless the partner has symptomatic balanitis 1
3. Severe infections can occur - In rare cases, SGLT2 inhibitors have been associated with serious infections like Fournier's gangrene, requiring immediate discontinuation of the medication 7
4. Oil-based creams and suppositories may weaken latex condoms and diaphragms 2
5. Self-medication with OTC preparations should only be advised for women previously diagnosed with vulvovaginal candidiasis who experience recurrence of the same symptoms 2

By following these treatment guidelines and prevention strategies, most genital mycotic infections caused by Jardiance can be effectively managed while continuing the diabetes medication.