Is it safe to initiate Jardiance (Empagliflozin) in a patient with an active urinary tract infection (UTI) and a kidney stone?

From the Guidelines

I would not recommend starting Jardiance (empagliflozin) in a patient with an active urinary tract infection (UTI) and kidney stone, as SGLT2 inhibitors like Jardiance can increase urinary glucose excretion, potentially worsening existing UTIs and complicating kidney stone management. According to the most recent evidence from 1, SGLT2 inhibitors have a high glucose-lowering efficacy and can provide benefits in terms of major adverse cardiovascular events (MACE) and heart failure (HF). However, they can also increase the risk of genital mycotic infections and intravascular volume depletion.

Given the patient's active UTI and kidney stone, it is crucial to prioritize the management of these conditions first. For the active UTI, ensure appropriate antibiotic treatment is completed first. For the kidney stone, management should include adequate hydration, pain control, and possibly urological intervention depending on stone size and symptoms.

Once both conditions have fully resolved (confirmed by negative urine culture and resolution of the kidney stone), Jardiance can be safely initiated if indicated for diabetes management. During this waiting period, alternative glucose-lowering medications such as metformin, DPP-4 inhibitors, or insulin can be used to maintain glycemic control without affecting the urinary tract conditions.

It is essential to consider the potential risks and benefits of SGLT2 inhibitors in patients with CKD, as they can provide renal benefits but also increase the risk of diabetic ketoacidosis and genital mycotic infections, as noted in 1 and 1. The most recent study 1 provides the highest quality evidence for the use of SGLT2 inhibitors in patients with type 2 diabetes, and its findings should be prioritized in clinical decision-making.

Key considerations for initiating SGLT2 inhibitors in patients with CKD include:

• Eligible patients should have an eGFR ≥20 ml/min per 1.73 m2
• High priority features include ACR ≥200 mg/g [≥20 mg/mmol]
• Patient selection should consider potential contraindications such as genital infection risk, diabetic ketoacidosis, foot ulcers, and immunosuppression
• Hypoglycemia risk and volume depletion risk should be assessed and managed accordingly, as noted in 1.

By prioritizing the management of the patient's UTI and kidney stone, and carefully considering the potential risks and benefits of SGLT2 inhibitors, clinicians can provide optimal care for patients with type 2 diabetes and CKD.

From the Research

Starting Jardiance in a Patient with Active UTI and Kidney Stone

• The patient's condition involves an active urinary tract infection (UTI) and a kidney stone, which can be a complicated situation for starting Jardiance (empagliflozin), an SGLT2 inhibitor used in the treatment of type 2 diabetes.
• According to the study 2, empagliflozin has been associated with a decreased risk of nephrolithiasis, which could be beneficial for patients with kidney stones. However, the study does not specifically address the situation of starting the medication in a patient with an active UTI and kidney stone.
• The management of UTIs associated with nephrolithiasis is crucial, as stated in the study 3. It involves treating the infection and considering the medical management of the stones, which may require complete eradication of the stones.
• In patients with kidney stones, the risk of infection and sepsis is higher, especially if the stones are infection stones or if the patient has anatomical anomalies or diabetes, as mentioned in the study 4.
• The study 5 highlights the importance of complete stone removal in the treatment of infected stones, which can help prevent further complications.
• When considering the use of Jardiance in a patient with a kidney stone and active UTI, it is essential to weigh the potential benefits of the medication against the risks of worsening the infection or causing other complications.
• The treatment of UTIs in patients with renal insufficiency or dialysis requires careful consideration of antimicrobial therapy, as these patients are at high risk of infection with antimicrobial-resistant pathogens, as stated in the study 6.

Key Considerations

• The patient's UTI should be treated appropriately before or concurrently with starting Jardiance.
• The type of kidney stone and its potential to cause further infections or complications should be considered.
• The patient's overall health status, including the presence of diabetes, kidney function, and other comorbidities, should be taken into account when deciding to start Jardiance.
• Close monitoring of the patient's condition, including urine cultures and kidney function tests, may be necessary after starting Jardiance.