Alternative Diabetes Medications When Switching from Jardiance Due to Yeast Infections
Switch to a GLP-1 receptor agonist, DPP-4 inhibitor, or thiazolidinedione as these medication classes do not increase the risk of genital yeast infections, while metformin remains the foundational therapy if not already prescribed.
Understanding the Problem
SGLT2 inhibitors like Jardiance (empagliflozin) increase urinary glucose excretion, which creates a glucose-rich environment in the genitourinary tract that promotes fungal overgrowth 1, 2, 3. Genital mycotic infections occurred in 3.7-4.7% of patients on empagliflozin in clinical trials, compared to 0% with placebo 4. This is a class effect of all SGLT2 inhibitors 5.
Recommended Alternative Medication Classes
First-Line Alternatives (No Increased Yeast Infection Risk)
Metformin: If not already prescribed or at maximum dose, optimize metformin therapy first as it remains the foundation of type 2 diabetes management without increasing infection risk 4
GLP-1 Receptor Agonists: These agents provide excellent glycemic control (HbA1c reductions of 1-1.5%), promote weight loss, and carry cardiovascular benefits without increasing genital infection risk 1, 2
DPP-4 Inhibitors: Well-tolerated oral agents with neutral effects on weight and no increased infection risk, though more modest HbA1c reductions (0.5-0.8%) compared to SGLT2 inhibitors 3
Thiazolidinediones (Pioglitazone): Effective glucose-lowering agents (HbA1c reductions of 0.8-1.4%) without genital infection risk, though associated with weight gain and fluid retention 6
Second-Line Alternatives (Use with Caution)
Sulfonylureas (Glimepiride): Effective for glycemic control but carry hypoglycemia risk and promote weight gain 7
Insulin: Reserve for patients requiring more intensive glycemic control, though it increases hypoglycemia risk and requires careful dose titration 7
Treatment of the Yeast Infection
Before or concurrent with switching medications, treat the active yeast infection:
For uncomplicated vulvovaginal candidiasis: Use topical azole antifungals (clotrimazole or miconazole intravaginally for 1-7 days) OR oral fluconazole 150 mg as a single dose 8
For recurrent infections: After initial treatment with fluconazole 150 mg single dose, consider maintenance therapy with fluconazole 150 mg weekly for 6 months 8
For male genital yeast infections: Topical azole antifungals are first-line treatment 8
Clinical Decision Algorithm
- Assess current diabetes control: Determine HbA1c target and gap from goal
- Evaluate cardiovascular risk: If high CV risk exists, prioritize GLP-1 receptor agonists for their proven cardiovascular benefits
- Consider patient factors: Weight goals (favor GLP-1 agonists), cost considerations, injection tolerance, and comorbidities
- Treat active infection: Initiate antifungal therapy per guidelines above 8
- Discontinue Jardiance: Stop SGLT2 inhibitor to eliminate ongoing glucose-mediated infection risk
- Initiate alternative agent: Start new medication at appropriate dose based on renal function and other patient factors
Important Caveats
Avoid other SGLT2 inhibitors: Do not switch to canagliflozin, dapagliflozin, or ertugliflozin as these carry the same class-related infection risk 1, 2
Address predisposing factors: Optimize diabetes control, evaluate for immunosuppression, and counsel on hygiene practices to prevent recurrence 8
Monitor closely: Follow up within 2-4 weeks to assess infection resolution and glycemic control on the new regimen
Combination therapy: Most patients will require combination therapy to achieve glycemic targets; ensure the new regimen provides adequate glucose-lowering efficacy 4