How to manage genital and skin infections in patients taking Jardiance (Empagliflozin)?

Management of Genital and Skin Infections in Patients Taking Jardiance (Empagliflozin)

Educate all patients starting Jardiance about genital mycotic infections before initiating therapy, emphasizing genital hygiene practices, and treat infections promptly with standard topical or oral antifungal agents without discontinuing Jardiance unless the infection is severe or recurrent. 1, 2

Pre-Treatment Patient Education and Risk Assessment

Before starting Jardiance, counsel patients specifically about:

• The increased risk of genital yeast infections, which occur in approximately 10-14% of women and 4-9% of men 3, 4
• Importance of daily genital hygiene to reduce infection risk 1
• Early warning signs: itching, redness, discharge, or discomfort in the genital area 2
• When to seek medical attention: if symptoms develop or worsen despite treatment 2

High-Risk Patients Requiring Extra Caution

History of recurrent genital candidiasis is a key consideration that may prompt more intensive monitoring or alternative therapy selection 1. Additional risk factors include:

• Female sex (4-fold higher risk than males, adjusted OR 4.22) 3
• Prior history of genital fungal infections (2.4-fold increased risk) 3
• Uncircumcised males with chronic recurrent infections 2
• HIV-positive patients (increased risk of severe infections including Fournier's gangrene) 5, 6
• Immunocompromised states, obesity, smoking, alcohol abuse 6

Treatment of Genital Mycotic Infections

For Uncomplicated Vulvovaginal Candidiasis in Women

First-line treatment options (choose one):

• Topical azoles: Clotrimazole 100 mg vaginal tablet daily for 7 days, or 500 mg single dose 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Oral fluconazole 150 mg single dose (most convenient option) 1

Continue Jardiance during treatment for uncomplicated infections 1. Most infections are mild to moderate in intensity, respond to standard antifungal therapies, and have a median symptom duration of a few days following treatment initiation 4.

For Male Genital Infections (Balanitis/Balanoposthitis)

Topical antifungal agents (clotrimazole, miconazole, or nystatin) applied to affected areas are effective 1, 2. The infection typically presents as rash or redness of the glans or foreskin 2.

Most male infections occur within the first year of treatment, with the majority in the first 4 months for females 4. Circumcision is rarely required; only a low proportion of males underwent this procedure across clinical trials 4.

For Complicated or Recurrent Infections

Recurrent vulvovaginal candidiasis (≥4 episodes per year):

• Initial therapy: 7-14 days of topical azole therapy OR fluconazole 150 mg repeated 3 days later 1
• Maintenance regimen: Fluconazole 150 mg weekly for 6 months after achieving mycologic remission 1

For non-albicans Candida species (C. glabrata, C. krusei):

• Topical boric acid or topical flucytosine (azoles are less effective) 1
• Consider obtaining vaginal cultures to identify unusual species 1

When to Discontinue Jardiance

Temporarily discontinue Jardiance in these specific situations:

• Fournier's gangrene (necrotizing fasciitis of the perineum/genitals) - a rare but life-threatening infection requiring emergency surgical debridement 5, 6
• Serious or recurrent genital infections that do not respond to standard treatment 1
• Multiple risk factors present (HIV, immunosuppression, poor glycemic control) with recurrent infections 6

Warning signs of Fournier's gangrene: fever, severe pain, swelling, tenderness, erythema, or necrosis of the genital or perineal area 5, 6. This requires immediate emergency evaluation and surgical intervention.

Skin Infections (Non-Genital)

For candidal skin infections and intertrigo (especially in skin folds):

• Topical azoles or polyenes: clotrimazole, miconazole, or nystatin 1
• Keep infected areas dry - this is critical for treatment success 1

For paronychia: drainage is the most important intervention 1

Monitoring and Follow-Up

• Return for evaluation only if symptoms persist or recur within 2 months of initial treatment 1
• Most genital infections with Jardiance occur early: within the first 4 months in females and first year in males 4
• Few patients experience multiple infections: only 2.3% of females and 0.9% of males had >1 event 4
• No consistent dose-dependent relationship exists between Jardiance dose and infection risk 4

Partner Management

Treatment of sexual partners is generally not recommended for candidal infections, as these are not typically sexually transmitted 1. However, consider treating male partners who have symptomatic balanitis with topical antifungal agents 1.

Common Pitfalls to Avoid

• Do not routinely discontinue Jardiance for mild-moderate genital infections - continue therapy while treating the infection 1, 4
• Do not delay treatment waiting for culture confirmation - treat based on clinical presentation 1
• Do not ignore recurrent infections in high-risk patients (HIV, immunosuppressed) - these may progress to severe infections 5, 6
• Do not use SGLT2 inhibitors in patients with active diabetic foot ulcers or severe peripheral arterial disease 1
• Avoid self-treatment with over-the-counter preparations for multiple episodes without medical evaluation, as this may delay diagnosis of other conditions 1