Management of Perineal Infection in a Patient on Dapagliflozin and Metformin
Discontinue dapagliflozin immediately and assess the severity of the perineal infection to rule out necrotizing fasciitis (Fournier's gangrene), which is a rare but life-threatening complication of SGLT2 inhibitors requiring urgent surgical intervention. 1
Immediate Assessment and Action
Evaluate for Fournier's gangrene if the patient presents with pain, tenderness, erythema, or swelling in the genital or perineal area, especially if accompanied by fever or malaise. 1 This necrotizing infection has been reported in both males and females taking SGLT2 inhibitors and requires:
- Immediate broad-spectrum antibiotics
- Urgent surgical debridement if confirmed
- Hospitalization with multiple surgeries often necessary 1
For uncomplicated genital mycotic infections (the more common scenario), which occur in 5-13% of patients on dapagliflozin: 2, 3, 4
- Treat with topical antifungal agents initially 2
- Oral antifungals can be used but require monitoring of QTc interval if patient is on antiarrhythmic medications 2
- Emphasize meticulous personal hygiene to reduce recurrence risk 2
Glycemic Control Strategy After Dapagliflozin Discontinuation
Continue metformin and add a DPP-4 inhibitor or GLP-1 receptor agonist as these classes have significantly lower rates of genital infections compared to SGLT2 inhibitors. 2 Specifically:
- DPP-4 inhibitors (sitagliptin, linagliptin, saxagliptin) combined with metformin show no increased risk of genital mycotic infections 2
- GLP-1 receptor agonists with proven cardiovascular benefit (liraglutide, semaglutide, dulaglutide) are recommended if the patient has established cardiovascular disease or high cardiovascular risk 2
Alternative option: Add a sulfonylurea (glimepiride, gliclazide) to metformin, which has lower risk of genital infections than SGLT2 inhibitors, though carries higher hypoglycemia risk. 2
Key Risk Factors and Prevention
Female sex and prior history of genital fungal infections are the only significant predictors of recurrent infections with SGLT2 inhibitors (adjusted OR 4.22 and 2.41, respectively). 5 If this patient has either risk factor and the infection resolves completely, do not restart dapagliflozin—choose an alternative agent permanently. 5
Monitoring During Transition
- Monitor blood glucose closely during medication transition to maintain glycemic control 1
- Reassess HbA1c within 3 months of therapy change 2
- Ensure complete resolution of infection before considering any medication adjustments 1
Important Caveat
While SGLT2 inhibitors like dapagliflozin have proven cardiovascular and renal benefits 2, the increased risk of genital infections (8-13% vs 0-5% with other agents) makes them inappropriate for patients experiencing active perineal infections. 2, 3, 4 The cardiovascular benefits can be achieved with GLP-1 receptor agonists, which do not carry this infection risk. 2