Is desensitization an option for a patient with a rash due to Jardiance (Empagliflozin)?

Management of Jardiance (Empagliflozin)-Associated Rash

Desensitization is not recommended for patients with rash due to Jardiance (empagliflozin); instead, discontinuation of the medication and alternative treatment options should be pursued.

Understanding Jardiance-Associated Skin Reactions

Skin reactions with SGLT2 inhibitors like empagliflozin (Jardiance) are relatively uncommon but can occur. Based on available evidence:

• Hypersensitivity adverse events with dapagliflozin (another SGLT2 inhibitor) occur in approximately 4.5% of patients, with rash (1.1%), eczema (0.6%), dermatitis (0.5%), and urticaria (0.5%) being the most common manifestations 1
• Case reports have documented skin reactions with empagliflozin, including bullous pemphigoid 2 and telangiectasia macularis eruptiva perstans 3

Management Algorithm for Empagliflozin-Associated Rash

Step 1: Assess Severity of the Rash

• Mild rash (localized, <10% BSA): Consider topical treatments
• Moderate rash (10-30% BSA): Discontinue empagliflozin, consider topical and oral treatments
• Severe rash (>30% BSA or with systemic symptoms): Immediate discontinuation and dermatology referral

Step 2: Immediate Management

1. Discontinue empagliflozin - Unlike some medications where desensitization protocols exist, there are no established desensitization protocols for SGLT2 inhibitors in current guidelines
2. Initiate symptomatic treatment:
   • Topical moderate-potency corticosteroids for localized areas
   • Emollients and soap substitutes to keep skin moisturized
   • Oral antihistamines for pruritus (cetirizine/loratadine 10mg daily or hydroxyzine 10-25mg QID) 4

Step 3: For Persistent or Severe Reactions

• Systemic steroids: For moderate-severe cases, prednisone 0.5-1 mg/kg/day for 1-2 weeks with tapering over 2-4 weeks 4
• Dermatology consultation: Especially for severe, persistent, or unusual presentations

Why Desensitization Is Not Recommended

While desensitization protocols exist for certain medications (like chemotherapeutic agents and aspirin) 5, there are several reasons why desensitization is not recommended for empagliflozin:

1. Lack of established protocols: Unlike platinum compounds or aspirin, there are no validated desensitization protocols for SGLT2 inhibitors in current guidelines

2. Alternative medications available: Type 2 diabetes has multiple treatment options, making it unnecessary to risk continued exposure to a medication causing hypersensitivity

3. Risk-benefit ratio: The potential risks of attempting desensitization outweigh benefits when safer alternatives exist

4. Type of reaction: Drug-induced skin reactions can range from mild to severe, and rechallenging patients who have had urticarial, bullous, or erythema multiforme-like eruptions can be dangerous 6

Alternative Management Options

Instead of desensitization, consider these alternatives:

1. Switch to another class of antidiabetic medication:

   • DPP-4 inhibitors
   • GLP-1 receptor agonists
   • Thiazolidinediones
   • Sulfonylureas
   • Metformin (if not already using)
   • Insulin therapy

2. Consider another SGLT2 inhibitor with caution: Cross-reactivity between SGLT2 inhibitors is possible but not well-documented. If attempting, close monitoring is essential.

Monitoring and Follow-up

• Monitor resolution of the rash after discontinuation
• Watch for signs of systemic involvement (fever, lymphadenopathy, organ dysfunction)
• If systemic steroids were used, implement a slow taper to prevent rebound flares 4
• Educate the patient about avoiding empagliflozin in the future and documenting this allergy

Common Pitfalls to Avoid

1. Attempting desensitization without established protocols: Unlike chemotherapy drugs where desensitization is well-established 5, there are no validated protocols for SGLT2 inhibitors

2. Continuing the medication despite skin reactions: This could lead to more severe reactions including potential progression to Stevens-Johnson syndrome or toxic epidermal necrolysis

3. Inadequate documentation: Ensure the reaction is well-documented in the patient's medical record to prevent future re-exposure

4. Tapering steroids too quickly: If systemic steroids are used, taper slowly to prevent rebound flares 4