How to treat mycotic infections in patients taking SGLT2 (Sodium-Glucose Linked Transporter 2) inhibitors?

Treatment of Mycotic Infections in Patients Taking SGLT2 Inhibitors

Mycotic infections in patients taking SGLT2 inhibitors should be treated with standard antifungal therapy while continuing the SGLT2 inhibitor for mild to moderate infections, but temporarily discontinuing the medication for severe infections until resolution. 1

Risk and Prevalence of Mycotic Infections with SGLT2 Inhibitors

• SGLT2 inhibitors significantly increase the risk of genital mycotic infections (primarily candida vaginitis in women and balanitis in men) compared to placebo (6% vs 1%) 1
• Women have a substantially higher risk of developing genital fungal infections than men when taking SGLT2 inhibitors (13.2% vs 3.3%) 2
• Patients with a prior history of genital fungal infections have more than double the risk of developing new infections when starting SGLT2 inhibitor therapy 2
• Studies in Indian populations have reported even higher rates, with up to 25.9% of patients experiencing at least one episode of genital mycotic infection 3

Treatment Algorithm for Mycotic Infections

Mild to Moderate Genital Mycotic Infections

• Treat with standard topical antifungal agents as first-line therapy 4, 1
• For more extensive infections, use oral fluconazole as a single dose 1, 5
• Continue SGLT2 inhibitor therapy during treatment of mild to moderate infections 1
• Most infections are not serious and typically resolve with a brief course of antifungal agents 4

Severe or Recurrent Infections

• Temporarily discontinue SGLT2 inhibitor until complete resolution of the infection 1
• For fluconazole-resistant infections (such as Candida glabrata), consider alternative antifungals with consultation from infectious disease specialists 6
• In cases of severe infections or Fournier's gangrene, immediately discontinue SGLT2 inhibitor and provide urgent medical attention 1
• Consider permanent discontinuation of SGLT2 inhibitors in patients with severe or recurrent infections 1

Prevention Strategies

• Counsel patients on proper genital hygiene before and during SGLT2 inhibitor therapy 1
• Educate patients about early symptoms of genital mycotic infections to facilitate prompt treatment 1
• Patient education about potential side effects and precautions significantly reduces infection incidence 3
• Consider screening for urogenital anatomical abnormalities before prescribing SGLT2 inhibitors, as these may predispose to more complicated infections 6

Special Considerations

• Patients with anatomical abnormalities of the urogenital tract may be at higher risk for complicated fungal infections including candidemia 6
• Immunocompromised patients require more careful monitoring for infections 1
• For patients with Type 1 diabetes, the risk of euglycemic diabetic ketoacidosis should be considered alongside infection risk 1
• Consider withholding SGLT2 inhibitors during periods of acute illness, prolonged fasting, or surgery 1

Common Pitfalls and Caveats

• Do not confuse symptoms of euglycemic ketoacidosis with symptoms of genitourinary infection 1
• Rare but serious complications like necrotizing fasciitis of the perineum have been reported with SGLT2 inhibitors 4
• Although there have been reports of pyelonephritis and urosepsis in patients taking SGLT2 inhibitors, large clinical trials have not shown increased rates of serious urinary tract infections 4
• The cardiovascular and renal benefits of SGLT2 inhibitors generally outweigh the risk of genital mycotic infections in most patients 4, 1