Treatment of Candida Infections in Men Taking Jardiance (Empagliflozin)
For men taking Jardiance (empagliflozin) who develop Candida infections, fluconazole is the recommended first-line treatment for most cases, while echinocandins should be used for more severe infections or those caused by resistant species like C. glabrata. 1
Risk Factors and Pathophysiology
SGLT2 inhibitors like Jardiance increase the risk of genital mycotic infections by causing glycosuria, which creates a favorable environment for fungal growth 2. Men taking Jardiance have approximately 3-4% risk of developing genital mycotic infections compared to 0.9% in those not taking the medication 2.
Risk factors specific to SGLT2 inhibitor-associated candidiasis include:
- Previous history of genital fungal infections (2.4× higher risk) 3
- Anatomical abnormalities of the urogenital tract 4
- Diabetes itself (independent risk factor)
Treatment Algorithm Based on Infection Type
1. Superficial Genital Candidiasis (Most Common)
- First-line: Fluconazole 150 mg oral single dose 1
- Alternative: Topical azole preparations (clotrimazole, miconazole) for 7-14 days
- For recurrent infections: Consider fluconazole 150 mg weekly for prophylaxis 1
2. Oropharyngeal Candidiasis
- First-line: Fluconazole 100-200 mg daily for 7-14 days 1
- Alternative: Itraconazole oral solution 200 mg daily for 7-14 days 1
- For fluconazole-resistant cases: Posaconazole 400 mg twice daily 1
3. Urinary Tract Candidiasis
- Asymptomatic candiduria: Generally does not require treatment; consider removing predisposing factors (including temporary discontinuation of Jardiance if appropriate) 5
- Symptomatic cystitis: Fluconazole 200 mg daily for 14 days 6, 5
- Pyelonephritis: Fluconazole 200-400 mg daily for 14 days 6
- For C. glabrata UTI (often fluconazole-resistant):
4. Invasive Candidiasis/Candidemia (Rare but Serious)
- First-line: Echinocandin (caspofungin: loading dose 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose 200 mg, then 100 mg daily) 1
- Duration: Minimum 14 days after documented clearance of Candida from bloodstream and resolution of symptoms 1
- Step-down therapy: Consider transition to fluconazole after clinical improvement for susceptible species 1
Species-Specific Considerations
- C. albicans: Usually fluconazole-susceptible; standard treatment applies 1
- C. glabrata: Often fluconazole-resistant; prefer echinocandins 1, 7
- C. krusei: Intrinsically fluconazole-resistant; use echinocandin, amphotericin B, or voriconazole 1
Management Pearls
Always obtain cultures before starting treatment for proper species identification and susceptibility testing 1
Source control is essential - consider temporary discontinuation of Jardiance in severe or recurrent cases 4, 8
Treatment duration:
- Superficial infections: 7-14 days
- Urinary tract infections: 14 days
- Invasive candidiasis: Minimum 14 days after negative cultures 1
Monitor for complications in patients with anatomical abnormalities of the urogenital tract, as they may develop more severe infections including candidemia 4
Prevention strategies:
- Good genital hygiene
- Loose-fitting cotton underwear
- Prompt treatment of initial infections
Important Caveats
Candidemia associated with SGLT2 inhibitors has been reported and can be life-threatening; consider this diagnosis in patients with persistent fever despite antibacterial therapy 4
In cases of recurrent infections despite appropriate treatment, consider permanent discontinuation of Jardiance after weighing cardiovascular benefits against infection risks 4, 8
Echinocandins generally achieve poor urinary concentrations but may still be effective for tissue-invasive disease or candidemia 5, 7
Patients with anatomical abnormalities of the urogenital tract should be evaluated before starting SGLT2 inhibitors due to higher risk of complicated infections 4