SGLT2 Inhibitors and UTI Management
For uncomplicated urinary tract infections (UTIs), SGLT2 inhibitors should NOT be discontinued and can be safely continued during treatment. 1 Only severe, recurrent, or complicated infections warrant temporary or permanent discontinuation.
Management Algorithm for UTIs in Patients on SGLT2 Inhibitors
Mild to Moderate UTIs
- Continue SGLT2 inhibitor therapy while treating the infection with standard antibiotics 1
- Treat the UTI according to standard protocols with appropriate antimicrobial therapy 1
- Monitor for resolution of symptoms during routine follow-up 1
Severe or Recurrent UTIs
- Consider temporary discontinuation of the SGLT2 inhibitor during treatment of severe infections 1
- Resume SGLT2 inhibitor after complete resolution of the infection 1
- Reassess the risk-benefit ratio in patients experiencing recurrent infections 1
- Consider permanent discontinuation only if infections are severe and recurrent 1
Fungal UTIs (Candida)
- Fungal UTIs are rare but can occur with SGLT2 inhibitor use due to glucosuria 2
- For Candida UTIs, discontinuation may be warranted as the infection may subside after stopping the medication 2
- Most genital mycotic infections (which are more common than fungal UTIs) can be treated with standard antifungal therapy while continuing the SGLT2 inhibitor 1
Evidence Supporting Continuation
Large randomized controlled trials demonstrate no significant increase in UTI risk with SGLT2 inhibitors. 3 Analysis of landmark trials (CANVAS, CREDENCE, DECLARE-TIMI 58, EMPA-REG) involving 38,723 participants showed UTI incidence of only 1.04% in the SGLT2 inhibitor group versus 1.15% in placebo 4. A nationwide Japanese claims database analysis found that SGLT2 inhibitors were actually negatively associated with UTIs in males (OR 0.74) and showed no increased risk in females (OR 0.99) 5.
Critical Distinction: Genital vs. Urinary Infections
Genital mycotic infections are far more common than UTIs with SGLT2 inhibitors (6% vs 1% compared to placebo) 6. These genital infections:
- Occur predominantly in women (candida vaginitis) and less commonly in men (balanitis) 6
- Are typically mild and respond to brief antifungal courses 6
- Rarely require SGLT2 inhibitor discontinuation 6
- Should not be confused with true UTIs 1
When to Discontinue Immediately
Discontinue SGLT2 inhibitors immediately for:
- Fournier's gangrene (necrotizing fasciitis of the perineum) - requires urgent surgical and antibiotic management 6, 1
- Pyelonephritis or urosepsis requiring hospitalization 6
- Signs of ketoacidosis (dyspnea, nausea, vomiting, abdominal pain) - do not confuse with UTI symptoms 6, 1
Special Populations Requiring Closer Monitoring
- Immunocompromised patients (including kidney transplant recipients) may have higher infection risk and need more careful monitoring 6, 1
- Female patients and older adults have significantly higher UTI risk when treated with SGLT2 inhibitors 7
- Insulin-requiring patients should maintain at least low-dose insulin to mitigate ketoacidosis risk 6, 1
Balancing Risks and Benefits
The cardiovascular and renal benefits of SGLT2 inhibitors generally outweigh the risk of genitourinary infections in most patients. 1 SGLT2 inhibitors provide:
- Significant reduction in kidney disease progression 6
- Decreased cardiovascular events and heart failure hospitalization 6
- Mortality benefits that far exceed the manageable risk of treatable infections 6
Common Pitfalls to Avoid
- Do not routinely discontinue SGLT2 inhibitors for simple UTIs - this deprives patients of critical cardiorenal protection 1, 3
- Do not confuse genital mycotic infections with UTIs - management differs significantly 1
- Do not mistake euglycemic ketoacidosis symptoms for UTI - check ketones if symptoms are atypical 1
- Do remember to withhold SGLT2 inhibitors 3-4 days before elective surgery or during acute illness to prevent ketoacidosis 6