What is the recommended treatment for an asymptomatic urinary tract infection (UTI) in a patient taking Farxiga (dapagliflozin)?

Management of Asymptomatic UTI in Patients Taking Farxiga (Dapagliflozin)

Do not treat asymptomatic bacteriuria in patients taking Farxiga (dapagliflozin). 1

Rationale and Evidence Base

The 2019 Infectious Diseases Society of America (IDSA) guidelines provide strong recommendations against screening for or treating asymptomatic bacteriuria (ASB) in most patient populations, including those with diabetes 1. The European Association of Urology (EAU) 2024 guidelines similarly recommend against treating catheter-associated asymptomatic bacteriuria in general 1.

While SGLT2 inhibitors like dapagliflozin (Farxiga) are associated with a slightly increased risk of urinary tract infections due to glucosuria, research shows:

• Most UTIs in patients on dapagliflozin are mild to moderate and respond well to standard antimicrobial treatment when symptomatic 2
• The incidence of diagnosed UTIs with dapagliflozin ranges from 3.6-5.7% compared to 3.7% with placebo 2
• There is no definitive dose relationship between glucosuria and UTI occurrence 2

Clinical Decision Algorithm

1. Confirm asymptomatic status:

   • Verify absence of urinary symptoms (dysuria, frequency, urgency, suprapubic pain)
   • Confirm absence of fever or systemic symptoms
   • Rule out delirium or acute mental status changes in elderly patients 1

2. Exceptions - treat ASB only in these specific scenarios:

   • Before urological procedures breaching the mucosa 1
   • In pregnant women 1

3. Monitoring recommendations:

   • Continue regular diabetes monitoring
   • Educate patient about symptoms of UTI that would warrant evaluation
   • No need for routine urine cultures in asymptomatic patients

Important Considerations

• Treating asymptomatic bacteriuria can lead to:

  • Antimicrobial resistance development 3
  • Disruption of protective urinary microbiome
  • Increased risk of Clostridioides difficile infection 1
  • Unnecessary medication adverse effects

• Patients on dapagliflozin should be educated about UTI symptoms that warrant medical attention:

  • New onset dysuria
  • Urinary frequency or urgency
  • Suprapubic discomfort
  • Fever or systemic symptoms

Special Considerations

• Immunocompromised patients: While standard guidelines still recommend against treating ASB, closer monitoring may be warranted as case reports suggest potentially higher risk of progression to severe infection 4

• Catheterized patients: The EAU strongly recommends against treating catheter-associated asymptomatic bacteriuria 1

• Elderly patients: Do not treat ASB in elderly patients with functional or cognitive impairment who experience falls or delirium without other UTI symptoms 1

By following these evidence-based recommendations, unnecessary antibiotic use can be avoided while maintaining appropriate vigilance for symptomatic infections in patients taking dapagliflozin.