Does balanitis necessitate discontinuation of SGLT2 (sodium-glucose cotransporter 2) inhibitors?

From the Guidelines

If you develop balanitis while taking an SGLT2 inhibitor, you should temporarily stop the medication and contact your healthcare provider. SGLT2 inhibitors like empagliflozin, dapagliflozin, and canagliflozin increase glucose in the urine, creating an environment that promotes fungal growth, particularly in warm, moist areas like the genital region, as noted in the 2018 ACC expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease 1. This is why genital infections, including balanitis in men, are a known side effect of these medications. Your doctor will likely recommend antifungal treatment for the infection and may consider whether to restart the SGLT2 inhibitor once the infection resolves, as suggested in the management of hyperglycemia in type 2 diabetes, 2018, a consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) 1. To prevent recurrence if the medication is restarted, maintain excellent genital hygiene, ensure thorough drying after bathing, wear loose cotton underwear, and consider preventive measures like antifungal powders. Some patients may need to permanently switch to a different class of diabetes medication if they experience recurrent infections, as indicated in the 2025 standards of care in diabetes, which provides guidance on pharmacologic approaches to glycemic treatment, including the use of SGLT2 inhibitors and their potential side effects 1. It is essential to weigh the benefits of SGLT2 inhibitors, including their glucose-lowering efficacy and cardiovascular benefits, against the potential risks, such as genital mycotic infections, and to closely monitor patients for any adverse effects, as recommended in the 2018 ACC expert consensus decision pathway 1.

Key considerations for the management of balanitis in patients taking SGLT2 inhibitors include:

• Temporarily stopping the medication and seeking medical attention if balanitis occurs
• Implementing preventive measures to reduce the risk of recurrence, such as maintaining good genital hygiene and using antifungal powders
• Weighing the benefits and risks of SGLT2 inhibitors and considering alternative treatment options if necessary
• Closely monitoring patients for any adverse effects, including genital mycotic infections and other potential side effects.

From the Research

Balanitis and SGLT2 Inhibitors

• The relationship between balanitis and SGLT2 inhibitors has been studied in several research papers 2, 3, 4, 5, 6.
• According to a study published in the Journal of diabetes and its complications, treatment with dapagliflozin, an SGLT2 inhibitor, is accompanied by an increased risk of vulvovaginitis or balanitis, related to the induction of glucosuria 2.
• However, the study found that most infections were mild or moderate and responded to standard antimicrobial treatment, and discontinuation due to these events was rare 2.
• A multidisciplinary expert consensus published in the Journal of clinical medicine recommends that routine discontinuation of SGLT2 inhibitors due to genitourinary adverse effects, including balanitis, is not recommended 3.
• The consensus states that preventive strategies, including identifying high-risk patients before initiating therapy, are critical for minimizing genitourinary adverse effects, and that therapy should be resumed as soon as possible, unless severe or persistent conditions contraindicate their use 3.
• A case report published in The American journal of case reports describes a patient who developed Fournier's Gangrene, a severe genital infection, while taking canagliflozin, an SGLT2 inhibitor 4.
• The report highlights the importance of prompt treatment and discontinuation of SGLT2 inhibitors in cases of severe genital infections 4.
• A retrospective cohort study published in Diabetes, obesity & metabolism found that SGLT2 inhibitors were associated with an approximately 3-fold increase in risk of genital infections, including balanitis, compared to other antidiabetic medications 5.
• Another study published in Urology found that use of SGLT2 inhibitors was associated with a higher frequency of urologic visits, balanitis/balanoposthitis, and other urologic diagnoses in patients with diabetes 6.

Discontinuation of SGLT2 Inhibitors

• The decision to discontinue SGLT2 inhibitors due to balanitis should be made on a case-by-case basis, taking into account the severity of the infection and the patient's individual risk factors 2, 3, 4, 5, 6.
• In general, mild to moderate cases of balanitis can be managed with standard antimicrobial treatment, and discontinuation of SGLT2 inhibitors may not be necessary 2, 3.
• However, in cases of severe or persistent balanitis, or in patients with a history of recurrent genital infections, discontinuation of SGLT2 inhibitors may be considered 3, 4.