How to manage fungal vaginosis (secondary to Sodium-Glucose Linked Transporter 2 inhibitors (SGLT2i) use)?

Management of Fungal Vaginitis Secondary to SGLT2 Inhibitor Use

For fungal vaginitis secondary to SGLT2 inhibitor use, treatment with topical antifungal agents or a single 150 mg oral dose of fluconazole is recommended as first-line therapy, with consideration of maintenance therapy for recurrent infections while continuing SGLT2 inhibitor treatment. 1

Diagnosis Confirmation

• Confirm diagnosis through:
  • Clinical symptoms (pruritus, irritation, vaginal soreness, dyspareunia)
  • Signs (vulvar edema, erythema, white thick discharge)
  • Wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast/hyphae
  • Normal vaginal pH (4.0-4.5)
  • Vaginal cultures if wet mount is negative 1

Treatment Algorithm for SGLT2i-Induced Fungal Vaginitis

First Episode (Uncomplicated)

First-line options:

• Oral therapy:

  • Fluconazole 150 mg single oral dose 1, 2

• Topical therapy options:

  • Clotrimazole 1% cream 5g intravaginally for 7 days
  • Clotrimazole 100 mg vaginal tablet for 7 days
  • Miconazole 2% cream 5g intravaginally for 7 days
  • Nystatin 100,000-unit vaginal tablet, one tablet for 14 days 1

Severe Acute Infection

• Fluconazole 150 mg, given every 72 hours for a total of 2 or 3 doses 1

For Non-albicans Species (particularly C. glabrata)

C. glabrata infections often don't respond to standard azole therapy:

1. Topical intravaginal boric acid, 600 mg daily in a gelatin capsule for 14 days 1
2. Nystatin intravaginal suppositories, 100,000 units daily for 14 days 1
3. Topical 17% flucytosine cream alone or with 3% AmB cream daily for 14 days 1

Recurrent Infections (Common with Continued SGLT2i Use)

• Induction phase: 10-14 days of topical agent or oral fluconazole
• Maintenance phase: Fluconazole 150 mg weekly for 6 months 1

Management Considerations with SGLT2 Inhibitors

Options for Continuing SGLT2i Therapy

1. Preventive approach:

   • Patient education about hygiene measures
   • Prophylactic antifungal therapy (fluconazole 150 mg weekly) 3

2. Treatment approach:

   • Treat each episode as it occurs with topical agents or single-dose fluconazole
   • Consider maintenance therapy if infections recur frequently 1, 3

When to Consider Discontinuing SGLT2i

• Multiple recurrent infections despite prophylaxis
• Severe infections affecting quality of life
• Patient preference after weighing benefits of SGLT2i against infection risk 3

Risk Factors for SGLT2i-Induced Fungal Vaginitis

Research shows significantly higher risk in:

• Female patients (13.2% vs 3.3% in males)
• Prior history of genital fungal infection (21.6% vs 7.3%) 4
• Overall prevalence can be as high as 25.9% in patients on SGLT2i 5

Prevention Strategies

• Maintain good genital hygiene
• Wear cotton underwear
• Avoid tight-fitting clothing
• Avoid irritants like perfumed soaps
• Proper education about side effects and precautions (significantly reduces infection incidence) 5

Clinical Pearls and Pitfalls

• Important: Most SGLT2i-induced fungal infections are mild and respond well to treatment 5
• Patients who are educated about potential side effects and precautions have significantly lower infection rates 5
• Consider testing for diabetes in patients with recurrent vulvovaginal candidiasis
• Avoid using oil-based creams and suppositories with latex condoms or diaphragms 1
• Treatment efficacy is lower in patients with recurrent vaginitis history (consider this when selecting therapy) 6

By following this structured approach to managing SGLT2i-induced fungal vaginitis, most patients can continue their diabetes medication while effectively controlling fungal infections and maintaining quality of life.