Can Jardiance (empagliflozin) contribute to the development of urinary tract infections (UTIs) and sepsis in a patient with uncontrolled diabetes mellitus and hyperglycemia?

Jardiance (Empagliflozin) Can Cause UTIs and Sepsis in Diabetic Patients

Jardiance should be discontinued immediately in this patient with sepsis from UTI, as SGLT2 inhibitors increase the risk of serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization. 1

Mechanism and Risk

Jardiance (empagliflozin) is an SGLT2 inhibitor that works by increasing urinary glucose excretion. This mechanism creates an environment conducive to urinary tract infections:

• The FDA label explicitly warns that SGLT2 inhibitors like Jardiance increase the risk for urinary tract infections 1
• Post-marketing reports have documented serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization in patients receiving SGLT2 inhibitors 1
• The presence of glucose in the urine (glucosuria) creates a favorable environment for bacterial growth

Management of Current Situation

For this 74-year-old female patient with sepsis from UTI:

1. Discontinue Jardiance immediately

2. Obtain blood cultures before starting antibiotics 2

3. Start appropriate empiric antibiotics based on local resistance patterns:

   • For sepsis: IV options including third-generation cephalosporins, which have shown superiority over fluoroquinolones for obstructive pyelonephritis 2
   • Adjust based on culture results when available

4. Evaluate for urinary obstruction with imaging (ultrasound or CT) 2

5. Address hyperglycemia (340 mg/dL) with alternative medications:

   • Resume long-acting insulin as the priority treatment
   • Consider restarting Trulicity (dulaglutide) when financially feasible

Risk Factors in This Patient

This patient has multiple risk factors that likely contributed to UTI and sepsis:

• Poorly controlled diabetes (blood glucose 340 mg/dL)
• Advanced age (74 years)
• Female gender
• Use of SGLT2 inhibitor (Jardiance)
• Medication non-compliance due to financial constraints

Alternative Diabetes Management

Given the patient's financial constraints and current infection:

1. Short-term: Insulin is essential for managing severe hyperglycemia during acute infection
2. Long-term options:
   • Explore patient assistance programs for insulin and Trulicity
   • Consider more affordable alternatives to Jardiance, such as metformin (if renal function permits)
   • Consult with social services for medication assistance programs

Important Monitoring and Follow-up

1. Renal function: SGLT2 inhibitors can cause acute kidney injury, especially in the setting of sepsis and volume depletion 1
2. Metabolic status: Monitor for euglycemic diabetic ketoacidosis, a rare but serious complication of SGLT2 inhibitors, particularly during acute illness 1, 3
3. Urological evaluation: Consider for recurrent or complicated UTIs 2

Special Considerations for Elderly Patients

• Elderly patients may present with atypical UTI symptoms such as altered mental status, functional decline, or fatigue rather than classic symptoms 2
• SGLT2 inhibitors can cause volume depletion, which elderly patients are more susceptible to 4
• Medication adjustments should consider renal function, which often declines with age 4

Prevention of Future UTIs

If diabetes control improves and the patient recovers fully:

• Increase fluid intake (at least 2L daily)
• Consider vaginal estrogen for postmenopausal women with recurrent UTIs 2
• Maintain optimal glycemic control with appropriate medications other than SGLT2 inhibitors

Remember that the risk of recurrent serious UTIs outweighs the benefits of continuing Jardiance in this patient with a history of urosepsis.