What is the recommended treatment for vaginal candidiasis in patients on Sodium-Glucose Linked Transporter 2 (SGLT-2) inhibitors?

Management of Vaginal Candidiasis in Patients on SGLT-2 Inhibitors

Primary Recommendation

Treat vaginal candidiasis in patients on SGLT-2 inhibitors with standard topical azole therapy for 7 days, and most patients can continue their SGLT-2 inhibitor with appropriate antifungal treatment. 1, 2

Treatment Approach

First-Line Therapy

Use standard topical azole antifungals as you would for any patient with vulvovaginal candidiasis:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

These topical formulations achieve 80-90% cure rates with symptom relief and negative cultures after therapy completion 1.

Oral Therapy Option

For patients who prefer oral treatment or when topical therapy is impractical:

• Fluconazole 150mg single dose can be used, though this is not specifically addressed in SGLT-2 inhibitor contexts 2
• A recent study showed 91% of SGLT-2 inhibitor-associated vulvitis cases with candidiasis were successfully treated with fluconazole 2

SGLT-2 Inhibitor Continuation Strategy

Most patients (54.5%) can continue their SGLT-2 inhibitor therapy when appropriate antifungal treatment is provided 2. The key is early recognition and prompt treatment:

• Initiate standard antifungal therapy immediately upon diagnosis 2
• Add topical treatments as needed to control inflammatory symptoms 2
• Monitor response to therapy closely 2

When to Discontinue SGLT-2 Inhibitor

Consider stopping the SGLT-2 inhibitor if:

• Candidiasis becomes recurrent despite appropriate antifungal therapy 2
• Symptoms persist or worsen despite standard treatment 2
• Patient develops resistant or complicated infection requiring discontinuation (occurred in 45% of cases in one series) 2

Special Considerations for SGLT-2 Inhibitor-Associated Vulvovaginitis

Unique Clinical Features

SGLT-2 inhibitors cause a characteristic inflammatory vulvitis with psoriasiform features, related to candidiasis in most cases (91%) 2. This occurs due to:

• Pharmacologically-induced glycosuria creating favorable conditions for Candida growth 3
• The mechanism is distinct from diabetes-related genital infections, as it is drug-induced 3

Enhanced Treatment Strategy

For SGLT-2 inhibitor-associated cases:

• Use 7-day topical azole regimens rather than shorter courses, as longer therapy may be needed for symptomatic resolution 4
• Consider adding topical anti-inflammatory agents to manage the psoriasiform inflammatory component 2
• Most infections are mild-to-moderate and respond to standard treatment 3

Management of Complicated or Recurrent Cases

Severe Vulvovaginitis

For extensive vulvar erythema, edema, excoriation, or fissure formation:

• Extend topical azole therapy to 7-14 days 1
• Alternative: Fluconazole 150mg in two sequential doses (second dose 72 hours after initial dose) 1

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

If recurrence develops while on SGLT-2 inhibitor:

• Obtain vaginal cultures to confirm diagnosis and identify non-albicans species 1
• Use longer initial therapy (7-14 days topical or fluconazole 150mg repeated 3 days later) 1
• Consider maintenance therapy: fluconazole 100-150mg once weekly for 6 months 1
• Strongly consider discontinuing SGLT-2 inhibitor if recurrence persists 2

Non-albicans Species

If C. glabrata or other non-albicans species identified (10-20% of recurrent cases):

• Extend therapy to 7-14 days with non-fluconazole azole 1
• If recurrence: boric acid 600mg vaginal capsule once daily for 2 weeks (70% eradication rate) 1

Common Pitfalls to Avoid

• Do not use single-dose or 3-day regimens in SGLT-2 inhibitor patients - the drug-induced glycosuria may require longer treatment courses 4
• Do not automatically discontinue the SGLT-2 inhibitor - over half of patients can continue therapy with appropriate antifungal treatment 2
• Do not treat asymptomatic colonization - 10-20% of women normally harbor Candida species without symptoms 1
• Do not routinely treat sexual partners - vulvovaginal candidiasis is not sexually transmitted, though partners with symptomatic balanitis may benefit from topical antifungals 1

Diagnostic Confirmation

Before treating, confirm diagnosis with:

• Clinical symptoms: vulvar pruritus, vaginal discharge, soreness, burning, dyspareunia, or external dysuria 1
• Vaginal pH ≤4.5 (normal pH suggests Candida rather than other causes) 1
• Wet preparation or Gram stain showing yeasts or pseudohyphae, or positive culture 1