What is the management of dapagliflozin (Forxiga) induced vaginosis?

Management of Dapagliflozin-Induced Vaginosis

Dapagliflozin-induced vaginosis should be treated with appropriate antifungal therapy for vulvovaginal candidiasis, as this is the most common type of vaginal infection associated with SGLT2 inhibitors. 1, 2

Understanding Dapagliflozin-Related Vaginal Infections

• Dapagliflozin, an SGLT2 inhibitor, causes glucosuria which increases the risk of vaginal yeast infections (vulvovaginal candidiasis) in women taking the medication 1, 2
• The FDA drug label specifically notes that women taking dapagliflozin may experience vaginal yeast infections with symptoms including vaginal odor, white or yellowish vaginal discharge, and vaginal itching 1
• Clinical studies show that genital infections occur in approximately 4.1-5.7% of patients taking dapagliflozin compared to 0.9% in placebo groups 2

Diagnostic Considerations

• Symptoms of dapagliflozin-induced vaginal yeast infection typically include:
  • Vaginal itching and irritation
  • White or yellowish discharge that may be lumpy (cottage cheese-like appearance)
  • Vaginal odor 1
• Diagnosis can be confirmed by:
  • Wet preparation or Gram stain showing yeasts or pseudohyphae
  • Normal vaginal pH (≤4.5) which helps distinguish from bacterial vaginosis (pH >4.5) 3, 4
• It's important to distinguish from cytolytic vaginosis (excessive lactobacilli) which has an acidic pH (<4.0) but different treatment approach 4

Treatment Recommendations

First-Line Treatment Options

• Over-the-counter antifungal medications are recommended as first-line therapy 1:
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days, OR
  • Clotrimazole 100mg vaginal tablet for 7 days, OR
  • Clotrimazole 100mg vaginal tablet, two tablets for 3 days, OR
  • Miconazole 2% cream 5g intravaginally for 7 days, OR
  • Miconazole 200mg vaginal suppository, one suppository for 3 days 3

Alternative Treatment Options

• For more severe or recurrent infections:
  • Fluconazole 150mg oral tablet, single dose 3
  • For complicated cases (severe symptoms, recurrent infections): extended-duration therapy with topical agents for 7-14 days or multiple doses of oral fluconazole 3

Follow-Up and Prevention

• If symptoms persist after using over-the-counter antifungal medications, patients should seek medical care 3, 1
• Preventive measures while continuing dapagliflozin:
  • Maintain good genital hygiene
  • Wear cotton underwear and loose-fitting clothes
  • Consider prophylactic antifungal therapy for recurrent infections 2

Special Considerations

• Most dapagliflozin-induced vaginal infections are mild to moderate and respond well to standard antifungal treatment 2
• Discontinuation of dapagliflozin due to vaginal infections is rare and usually not necessary 2
• If infections are recurrent and severe despite appropriate treatment, discuss with healthcare provider about potential medication adjustment 1
• No clear dose-response relationship between dapagliflozin dosage and genital infection risk has been demonstrated 2

Important Distinctions

• Do not treat with antibiotics (metronidazole or clindamycin) as these are indicated for bacterial vaginosis, not the fungal infections typically caused by dapagliflozin 3, 5
• If symptoms suggest bacterial vaginosis (fishy odor, thin discharge, pH >4.5), different treatment would be required 3, 5
• If cytolytic vaginosis is suspected (excessive lactobacilli), treatment with sodium bicarbonate douches would be appropriate instead of antifungals 4