Management of Genitourinary Infections During SGLT2i Use
Genital mycotic infections are a known complication of SGLT2i therapy and require prompt management with antifungal treatment while maintaining daily hygienic measures to prevent recurrence. 1
Prevalence and Risk Factors
- Genital mycotic infections occur in approximately 6% of patients on SGLT2i therapy compared to 1% in those on placebo 1
- Women have a higher risk of developing genital infections than men during SGLT2i treatment 1, 2
- The risk appears consistent across different SGLT2i agents (empagliflozin, dapagliflozin, canagliflozin) 3
- Urinary tract infections (UTIs) are less common than genital infections in patients using SGLT2i 2
Prevention Strategies
- Counsel patients on proper genital hygiene before and during SGLT2i therapy 1, 3
- Advise adequate hydration (drinking plenty of water) to reduce infection risk 3
- Educate patients about early symptoms of genitourinary infections to facilitate prompt treatment 1
- Consider DPP-4 inhibitor combination therapy, which may moderate the risk of genitourinary infections associated with SGLT2i (risk ratio 0.51,95% CI 0.28-0.92) 4
Management Algorithm for Genitourinary Infections
1. For Genital Mycotic Infections:
- Treat most genital mycotic infections with standard antifungal therapy 1
- For women: topical or oral antifungal agents for vulvovaginal candidiasis 5
- For men: topical antifungal treatment for balanitis 5
- Continue SGLT2i therapy during treatment of mild to moderate infections 1
2. For Urinary Tract Infections:
- Treat with appropriate antibiotics based on culture and sensitivity 6
- Consider temporary discontinuation of SGLT2i in severe or recurrent UTIs 1
- Resume SGLT2i after complete resolution of the infection 1
3. For Severe Infections:
- Discontinue SGLT2i immediately for severe infections or Fournier's gangrene 1
- Provide urgent medical attention and appropriate surgical and antibiotic management 1
- Consider permanent discontinuation of SGLT2i in cases of severe or recurrent infections 1
Special Considerations
- Immunocompromised patients, including kidney transplant recipients, may be at higher risk for infections and require more careful monitoring 1
- Patients with Type 1 diabetes may have different risk profiles for infections compared to those with Type 2 diabetes 1
- Consider withholding SGLT2i during periods of acute illness, prolonged fasting, or surgery when patients may be at greater risk for complications 1
Follow-up Recommendations
- Monitor patients for symptoms of genitourinary infections during routine follow-up visits 1
- Advise patients to report symptoms promptly rather than waiting for scheduled appointments 3
- Reassess the risk-benefit ratio of continuing SGLT2i therapy in patients with recurrent infections 1
Common Pitfalls and Caveats
- Do not confuse euglycemic ketoacidosis (another SGLT2i complication) with symptoms of genitourinary infection 1
- Severe cases of Fournier's gangrene, though rare, have been reported and require immediate medical attention 1
- Maintain at least low-dose insulin in insulin-requiring individuals to mitigate the risk of ketoacidosis 1
- The benefits of SGLT2i on kidney and cardiovascular outcomes generally outweigh the risk of genitourinary infections in most patients 1