What is the management plan for a patient with a urinary tract infection (UTI) who is taking a sodium-glucose cotransporter 2 (SGLT-2) inhibitor?

Management of UTI in Patients Taking SGLT-2 Inhibitors

For patients with urinary tract infection (UTI) who are taking SGLT-2 inhibitors, the SGLT-2 inhibitor should be temporarily discontinued during the acute infection and antibiotic treatment, and resumed after resolution of the infection.

Initial Assessment and Management

Step 1: Evaluate and Treat the UTI

• Use trimethoprim-sulfamethoxazole as first-line treatment for uncomplicated UTIs
  • Standard adult dosage: 1 double-strength tablet (160 mg trimethoprim/800 mg sulfamethoxazole) every 12 hours for 10-14 days 1
  • Adjust dosage for renal impairment:
    • CrCl >30 mL/min: Standard regimen
    • CrCl 15-30 mL/min: Half the usual regimen
    • CrCl <15 mL/min: Not recommended 1

Step 2: Temporarily Discontinue SGLT-2 Inhibitor

• SGLT-2 inhibitors should be temporarily withheld during acute illness, especially with risk of dehydration 2
• This is particularly important because:
  • UTIs are more common in patients taking SGLT-2 inhibitors (33.49% vs 11.72% in non-SGLT-2 inhibitor users) 3
  • Infection is the most common trigger for euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors 4

Monitoring During Infection

• Monitor for signs of:

  • Dehydration and volume depletion
  • Hyperglycemia requiring alternative management
  • Progression to pyelonephritis or urosepsis
  • Euglycemic diabetic ketoacidosis (rare but serious complication) 4

• If the patient is on insulin or sulfonylureas, adjust doses to prevent hypoglycemia while the SGLT-2 inhibitor is held 2

Resuming SGLT-2 Inhibitor After UTI Resolution

• Resume SGLT-2 inhibitor after complete resolution of the UTI and when the patient is clinically stable 2
• When restarting:
  • Monitor kidney function (expect an initial "eGFR dip" of 3-5 mL/min/1.73 m² in the first 4 weeks) 2
  • Readjust concomitant medications (insulin, sulfonylureas, diuretics) 2

Prevention of Recurrent UTIs in Patients on SGLT-2 Inhibitors

Risk Assessment

• Identify high-risk patients:
  • Female gender (significantly higher risk) 3
  • Older age 3
  • History of recurrent UTIs 4
  • Concomitant use of certain medications (DPP-4 inhibitors, thiazolidinediones, glinides, statins, ARBs, and calcium channel blockers may increase risk through drug-drug interactions) 5

Preventive Measures

• Implement daily hygiene practices to keep genital area clean and dry 2
• Consider discontinuing SGLT-2 inhibitor in patients with:
  • Recurrent or severe UTIs 4
  • Fungal UTIs (rare but reported with SGLT-2 inhibitor use) 6

Special Considerations

For Patients with Reduced Kidney Function

• SGLT-2 inhibitors can be used in patients with eGFR ≥20 mL/min/1.73 m² 2
• For patients with eGFR <45 mL/min/1.73 m², SGLT-2 inhibitors have reduced glucose-lowering efficacy but may still provide cardiorenal benefits 2
• Consider alternative diabetes medications for glycemic control in patients with frequent UTIs and reduced kidney function

Patient Education

• Educate patients on:
  • Early recognition of UTI symptoms
  • Importance of adequate hydration
  • Implementation of "STOP DKA" protocol during illness (Stop SGLT2 inhibitor, Test for ketones, maintain fluid and carbohydrate intake, insulin as needed) 2
  • When to seek medical attention

Common Pitfalls to Avoid

• Failure to temporarily discontinue SGLT-2 inhibitors during acute UTI
• Inadequate adjustment of concomitant medications when SGLT-2 inhibitor is held
• Overlooking the risk of euglycemic diabetic ketoacidosis during infection
• Restarting SGLT-2 inhibitor before complete resolution of the UTI
• Failing to provide preventive education for patients at high risk of recurrent UTIs

While some studies suggest no significantly increased risk of UTIs with SGLT-2 inhibitors 7, the most recent evidence indicates a substantially higher incidence 3, warranting a cautious approach, especially in high-risk patients.