Is empagliflozin (SGLT2 inhibitor) contraindicated in patients with infection?

Is Empagliflozin Contraindicated in Infection?

Empagliflozin is not absolutely contraindicated in infection, but it should be temporarily discontinued during acute illness to prevent serious complications, particularly euglycemic diabetic ketoacidosis and volume depletion. 1

Sick Day Management Protocol

Empagliflozin must be held during any acute illness, particularly when patients experience fever, vomiting, diarrhea, or reduced food and fluid intake. 1 This is a critical safety measure because:

• Acute illness is a major trigger for diabetic ketoacidosis in patients taking SGLT2 inhibitors, even when blood glucose levels remain normal or only mildly elevated (<200 mg/dL). 1
• The diuretic effect of empagliflozin combined with illness-related fluid losses significantly increases the risk of hypovolemia and volume depletion. 1
• Patients requiring insulin are at particularly high risk for ketoacidosis during concurrent illness. 1

Specific Infection-Related Risks

Genital and Urinary Tract Infections

• Genital mycotic infections occur more frequently with empagliflozin (approximately 6% of patients) compared to placebo (1%), with higher risk in women than men. 1, 2, 3
• Most genital infections are mild to moderate in severity and easily treated, but severe cases of Fournier gangrene have been reported (though rare). 1
• Serious urinary tract infections, including pyelonephritis and urosepsis, show similar incidence to placebo overall, but are slightly higher in women taking empagliflozin. 2
• Empagliflozin should be discontinued immediately if patients develop severe or worsening genital infections requiring urgent medical attention. 1

When to Withhold Empagliflozin

Temporarily discontinue empagliflozin in these specific scenarios:

• Any intercurrent illness requiring hospitalization 1
• Fever, vomiting, or diarrhea 1
• Reduced ability to eat or drink normally 1
• At least 3 days before any elective or anticipated invasive procedures 1
• Signs or symptoms of ketoacidosis (malaise, nausea, vomiting, abdominal pain) 1

Critical Safety Considerations During Illness

• Maintain at least low-dose insulin in insulin-requiring patients even when empagliflozin is held, as complete insulin cessation dramatically increases DKA risk. 1
• Monitor for ketoacidosis even with normal blood glucose levels using blood or urine ketone testing if patients develop nonspecific symptoms. 1
• Patients should seek immediate medical attention if symptoms of ketoacidosis develop. 1

When to Restart Empagliflozin

Resume empagliflozin only after:

• The patient has fully recovered from acute illness 1
• Normal oral intake is re-established 1
• Volume status has been assessed and corrected if needed 1

Common Pitfall to Avoid

Do not continue empagliflozin during active infection or acute illness simply because the patient's blood glucose appears well-controlled. The risk of euglycemic ketoacidosis and volume depletion outweighs any glycemic benefit during periods of physiologic stress. 1

Long-Term Safety Profile

Outside of acute illness, empagliflozin demonstrates favorable safety:

• No increased risk of serious adverse events, fatal adverse events, or treatment discontinuation compared to placebo 2
• Lower incidence of acute kidney injury compared to placebo 2
• No increased risk of hypoglycemia (except when combined with sulfonylureas or insulin) 4, 5, 3
• Daily hygienic measures can reduce the risk of genital infections 1