Is switching from Jardiance (empagliflozin) to Mounjaro (tirzepatide) a better option for a patient with a history of cardiac stent placement and impaired renal function, experiencing recurrent UTIs and yeast infections, and considering circumcision at 58?

Switching from Jardiance to Mounjaro for a Patient with Recurrent UTIs and Yeast Infections

Switching from Jardiance (empagliflozin) to Mounjaro (tirzepatide) is strongly recommended for this 58-year-old patient with a history of cardiac stent and renal impairment who is experiencing recurrent UTIs and yeast infections.

Rationale for Medication Switch

Jardiance (empagliflozin) is associated with a significantly increased risk of genital mycotic infections and urinary tract infections compared to placebo. According to the FDA label:

• Genital mycotic infections occur in 3.7-4.1% of patients on Jardiance compared to 0.9% on placebo 1
• UTIs are more common in patients on Jardiance, particularly in those with a history of chronic or recurrent UTIs 1
• Phimosis specifically occurs more frequently in male patients on Jardiance (0.1%) than placebo (0%) 1

Benefits of Current Therapy vs. Risks

While Jardiance offers significant renal and cardiovascular benefits:

• Reduces risk of progression of kidney disease by 39% in patients with chronic kidney disease 2
• Reduces cardiovascular death by 29% in patients with established cardiovascular disease and CKD 3

However, these benefits must be weighed against:

• The patient's ongoing UTIs and yeast infections
• The consideration of circumcision at age 58 to address these issues
• Quality of life impairment from recurrent infections

Management Algorithm

1. First step: Discontinue Jardiance and switch to Mounjaro

   • Mounjaro (tirzepatide) offers glycemic control without increasing UTI or genital infection risk
   • This eliminates the need for circumcision surgery at age 58

2. If switching is not possible, consider these alternatives before proceeding with circumcision:

   • Antifungal prophylaxis for yeast infections:
     • Fluconazole 200mg weekly for prophylaxis 4
   • UTI prevention strategies:
     • Methenamine hippurate (strong recommendation) 4
     • Vaginal estrogen in postmenopausal women 4
     • Immunoactive prophylaxis 4
     • Cranberry products (though evidence is contradictory) 4

3. If infections persist despite medication change:

   • Obtain urine culture to guide targeted antibiotic therapy 4, 5
   • Consider short-term antimicrobial prophylaxis 4

Important Considerations

• Medication efficacy: Both Jardiance and Mounjaro effectively control blood glucose, but through different mechanisms
• Infection risk: SGLT2 inhibitors like Jardiance increase glucose in urine, creating favorable conditions for fungal growth and bacterial UTIs
• Cardiovascular benefits: Both medications offer cardiovascular benefits, though through different mechanisms
• Renal protection: While Jardiance has established renal protective effects, this benefit must be balanced against quality of life impairment from recurrent infections

Common Pitfalls to Avoid

• Continuing SGLT2 inhibitor despite recurrent infections: This can lead to serious complications like urosepsis 1
• Unnecessary surgery: Circumcision at age 58 carries surgical risks that may be avoided by medication change
• Inadequate infection treatment: Ensure proper diagnosis and treatment of current infections before switching medications
• Overlooking non-pharmacological measures: Increased fluid intake and other behavioral modifications can help reduce UTI risk 4

By switching from Jardiance to Mounjaro, the patient can maintain glycemic control and cardiovascular protection while eliminating the medication-induced risk factor for recurrent UTIs and yeast infections, potentially avoiding the need for circumcision.