What are the considerations for using Jardiance (Empagliflozin) in patients with a history of urosepsis?

Jardiance (Empagliflozin) in Patients with History of Urosepsis

Jardiance (empagliflozin) should generally be avoided in patients with a history of urosepsis due to the increased risk of recurrent urinary tract infections and potential for serious complications. 1

Risk Assessment and Contraindications

Empagliflozin carries specific warnings related to urinary tract infections that are particularly relevant for patients with a history of urosepsis:

• The FDA label explicitly lists "Urosepsis and Pyelonephritis" as a warning, requiring evaluation of patients for signs and symptoms of urinary tract infections and prompt treatment if indicated 1
• SGLT2 inhibitors have been associated with serious urinary tract infections including pyelonephritis and urosepsis 1, 2
• Case reports document septic shock due to pyelonephritis and bacteremia in patients receiving empagliflozin 2

Decision Algorithm for Empagliflozin Use in Patients with History of Urosepsis

Absolute Contraindications (Do Not Use)

• Patients with recent urosepsis (within past 6 months)
• Patients with recurrent episodes of urosepsis
• Patients with anatomical abnormalities predisposing to urinary stasis
• Patients with indwelling urinary catheters
• Patients with severe renal impairment (eGFR <20 mL/min/1.73 m²) 3

Relative Contraindications (Use with Extreme Caution)

• Single remote episode of urosepsis with complete resolution and no predisposing factors
• Patients with history of uncomplicated UTIs (not urosepsis)

Monitoring Requirements if Empagliflozin is Used

If the decision is made to use empagliflozin in a patient with a remote history of urosepsis (after careful risk assessment):

1. Baseline Assessment:

   • Comprehensive urological evaluation to rule out structural abnormalities
   • Baseline urinalysis and culture to confirm absence of current infection
   • Assessment of renal function (eGFR)

2. Ongoing Monitoring:

   • Regular urinalysis (every 1-3 months)
   • Immediate evaluation for any urinary symptoms
   • Patient education on symptoms requiring urgent medical attention:
     • Fever, chills, flank pain
     • Changes in mental status
     • Significant decrease in urine output 4

3. Temporary Discontinuation:

   • During periods of reduced oral intake or fluid losses
   • Before scheduled surgery
   • At first sign of urinary tract infection 1

Alternative Therapies

For patients with a history of urosepsis who need glucose-lowering therapy, consider:

• GLP-1 receptor agonists
• DPP-4 inhibitors
• Metformin (if renal function permits)
• Thiazolidinediones
• Insulin therapy

Clinical Pearls and Pitfalls

• Key Pitfall: Underestimating the risk of recurrent urosepsis in patients with prior episodes. Urosepsis accounts for approximately 25% of all sepsis cases and carries significant mortality risk 5, 6
• Important Consideration: Urosepsis is often associated with complicated UTIs involving parenchymatous urogenital organs and frequently associated with obstructive uropathy 5
• Prevention Strategy: If empagliflozin is used, ensure optimal hydration and urge patients to maintain adequate fluid intake to reduce risk of urinary stasis

Special Populations

• Elderly patients: Higher risk of adverse reactions related to volume depletion and reduced renal function; use with extreme caution if history of urosepsis 1
• Patients with renal impairment: Higher incidence of adverse reactions; avoid if eGFR <20 mL/min/1.73 m² for heart failure treatment 3

The European Association of Urology guidelines emphasize the importance of identifying and controlling risk factors for urinary tract infections 3, which is particularly relevant when considering medications like empagliflozin that may increase UTI risk in vulnerable populations.