SGLT2 Inhibitors and Asymptomatic UTI
Continue SGLT2 inhibitors in patients with asymptomatic bacteriuria (ASB) without interruption, as there is no indication for screening or treating ASB in diabetic patients, and the cardiovascular and renal benefits of SGLT2 inhibitors substantially outweigh any theoretical infection concerns. 1, 2
Key Evidence on Asymptomatic Bacteriuria
- Asymptomatic bacteriuria occurs 2-3 times more frequently in diabetic women compared to non-diabetic women, but treatment of ASB has no impact on preventing symptomatic UTIs or declining renal function 2
- There is no indication for screening for or treating asymptomatic bacteriuria in diabetic patients 2
- Large randomized controlled trials (EMPA-REG OUTCOME, CANVAS, CANVAS-R, DECLARE-TIMI 58) demonstrated no difference in rates of symptomatic UTIs between SGLT2 inhibitors and placebo 1
SGLT2 Inhibitor Safety Profile for UTIs
- The American College of Cardiology confirms that SGLT2 inhibitors do not increase the risk of urinary tract infections in patients with any level of glycemic control 1
- Analysis of 60,082 participants across landmark trials showed UTI rates of 1.04% with SGLT2 inhibitors versus 1.15% with placebo—actually numerically lower 3
- No consistent evidence exists linking A1c levels, glycosuria, or SGLT2 inhibitor use with increased risk of symptomatic UTIs 2
Clinical Management Algorithm
For patients with asymptomatic bacteriuria:
- Do not screen for ASB routinely 2
- If ASB is incidentally discovered, do not treat it 2
- Continue SGLT2 inhibitor therapy without modification 1
- Maintain standard hygienic counseling to prevent genital mycotic infections (the actual infection risk with SGLT2 inhibitors) 4
For patients with symptomatic UTI:
- Treat the symptomatic UTI with appropriate antibiotics per standard protocols 2
- Continue SGLT2 inhibitor during treatment unless the patient meets sick day criteria (prolonged fasting, critical illness, reduced oral intake) 4
- Resume SGLT2 inhibitor immediately after acute illness resolves 4
Important Caveats
- Genital mycotic infections (not UTIs) are the actual genitourinary concern with SGLT2 inhibitors, occurring in approximately 6% versus 1% on placebo 1
- These genital infections are typically mild, respond to brief antifungal courses, and rarely require SGLT2 inhibitor discontinuation 1
- Caution is warranted in male patients with bladder outlet obstruction or significant post-void residual volumes (>150-180 mL), as urinary stasis may increase infection risk 5
- The cardiovascular and renal benefits of SGLT2 inhibitors (58 fewer kidney failure events per 1000 patients, 39% reduction in CKD progression) far outweigh the minimal infection risks 6, 1
Continuation During Established Therapy
- Once initiated, continue SGLT2 inhibitors even if eGFR falls below 20 mL/min/1.73 m² unless dialysis is initiated 4, 6
- The initial reversible eGFR decline of 3-5 mL/min/1.73 m² in the first 4 weeks is expected and does not require discontinuation 4, 6
- Implement sick day protocols: temporarily hold SGLT2 inhibitors only during acute illness with reduced oral intake, prolonged fasting, or critical medical illness 4, 6