SGLT2 Inhibitors and Asymptomatic Urinary Tract Infections
No, SGLT2 inhibitors should NOT be discontinued in patients with asymptomatic urinary tract infections (asymptomatic bacteriuria). Continue the SGLT2 inhibitor and treat only if the patient develops symptomatic infection.
Key Evidence on UTI Risk with SGLT2 Inhibitors
Large randomized controlled trials demonstrate that SGLT2 inhibitors do not increase the risk of urinary tract infections. The EMPA-REG OUTCOME, CANVAS, and CANVAS-R trials showed no difference in rates of any urinary tract infections or serious urinary tract infections between SGLT2 inhibitors and placebo 1. This finding holds true despite theoretical concerns about glycosuria creating a favorable environment for bacterial growth 1.
Recent prospective cohort data specifically examining asymptomatic bacteriuria confirms this safety profile. A 2024 study of 143 women with type 2 diabetes initiated on SGLT2 inhibitors found that asymptomatic pyuria and bacteriuria at baseline were not risk factors for developing symptomatic UTI 2. The relative risk of UTI was 0.92 (95% CI: 0.42-2.01) for bacteriuria and 1.2 (95% CI: 0.47-3.08) for combined pyuria plus bacteriuria 2.
Management Algorithm for Genitourinary Issues
For Asymptomatic Bacteriuria:
- Continue SGLT2 inhibitor therapy without interruption 3, 1
- Do not treat asymptomatic bacteriuria unless specific indications exist (pregnancy, planned urologic procedures) 2
- Monitor for development of symptomatic infection during routine follow-up 3
For Symptomatic UTIs:
- Continue SGLT2 inhibitor during treatment of mild to moderate symptomatic UTIs 3, 4
- Treat with standard antibiotic therapy appropriate for the causative organism 3
- Consider temporary discontinuation only for severe or recurrent UTIs 3, 4
- Resume SGLT2 inhibitor after complete resolution of severe infections 3
For Genital Mycotic Infections:
- Genital mycotic infections occur in approximately 6% of SGLT2 inhibitor users versus 1% on placebo 3, 1
- Treat with standard antifungal therapy while continuing SGLT2 inhibitor 3, 4
- These infections are typically mild and respond to brief antifungal courses 1
When to Discontinue SGLT2 Inhibitors
Immediate discontinuation is required only for:
- Fournier's gangrene (necrotizing fasciitis of the perineum) 3, 4
- Severe infections requiring hospitalization 3
- Recurrent severe infections where risks outweigh cardiovascular and renal benefits 3, 4
Risk Stratification Considerations
Higher-risk patients who warrant closer monitoring but not prophylactic discontinuation include:
- Patients with recurrent UTI history (use cautiously as cardiovascular and renal benefits may still outweigh risks) 1
- Immunocompromised patients, including kidney transplant recipients 3, 1
- Patients with poor glycemic control (higher HbA1c associated with increased UTI risk) 5
- Female patients (inherently higher UTI risk) 5
Critical Clinical Context
The cardiovascular and renal benefits of SGLT2 inhibitors generally outweigh the risk of genitourinary infections in most patients 3, 1. SGLT2 inhibitors reduce the risk of ESRD by 32%, cardiovascular death or heart failure hospitalization by 31%, and major adverse cardiovascular events by 20% in patients with advanced CKD 6. These substantial mortality and morbidity benefits should not be sacrificed for asymptomatic bacteriuria, which does not increase symptomatic UTI risk 2.
Common Pitfalls to Avoid
- Do not confuse the initial reversible eGFR decline of 3-5 mL/min/1.73 m² with acute kidney injury requiring discontinuation 6, 1
- Do not routinely screen for or treat asymptomatic bacteriuria in patients on SGLT2 inhibitors 2
- Do not discontinue SGLT2 inhibitors preemptively based solely on a history of prior UTIs without assessing current infection status 1
- Remember to discontinue SGLT2 inhibitors 3 days before elective invasive procedures (4 days for ertugliflozin) to reduce diabetic ketoacidosis risk 6