What are the risks and management strategies for urinary tract infections (UTIs) in patients taking Jardiance (empagliflozin) for diabetes management, particularly in those with a history of recurrent UTIs or underlying medical conditions?

Jardiance (Empagliflozin) and Urinary Tract Infections

Risk Profile

Jardiance increases the risk of urinary tract infections (UTIs), particularly in women, and patients should be monitored and treated promptly if UTIs develop. 1

The FDA-approved labeling for Jardiance explicitly warns about urosepsis and pyelonephritis, stating that clinicians must "evaluate patients for signs and symptoms of urinary tract infections and treat promptly, if indicated." 1 In clinical trials, UTIs occurred more frequently in Jardiance-treated patients compared to placebo, with rates of 7.6% and 9.3% for the 10 mg and 25 mg doses respectively, versus 7.6% for placebo. 1 The incidence was substantially higher in female patients (16.6-18.4%) compared to male patients (3.2-4.1%). 1

High-Risk Populations Requiring Extra Caution

Patients with a history of chronic or recurrent UTIs are at significantly increased risk and were more likely to experience UTIs when treated with Jardiance. 1

• Women face 4-5 times higher UTI risk than men when taking SGLT2 inhibitors like Jardiance 1, 2
• Elderly patients have higher incidence of adverse reactions related to volume depletion and reduced renal function, which may compound UTI risk 1
• Patients with bladder outlet obstruction should receive Jardiance with extreme caution, as urinary stasis combined with glucosuria creates an environment highly conducive to bacterial growth 3
• Patients with renal impairment (eGFR < 45 mL/min/1.73 m²) should not be initiated on Jardiance 1

Management Strategy

Before Initiating Jardiance

Screen for and address any underlying urological abnormalities, particularly in patients with recurrent UTI history. 4

• Obtain baseline renal function (eGFR) and do not initiate if eGFR < 45 mL/min/1.73 m² 1
• Consider screening for asymptomatic bacteriuria in high-risk patients, though routine screening is not recommended for well-controlled diabetics 4
• Assess for bladder outlet obstruction in male patients with lower urinary tract symptoms 4, 3

During Treatment

Educate patients to recognize UTI symptoms (dysuria, frequency, urgency) and seek prompt medical attention. 4

• Monitor for signs and symptoms of UTIs at each visit 1
• If UTI is suspected, obtain urine culture before initiating antimicrobial therapy to guide appropriate treatment 4
• Most UTIs associated with Jardiance are mild to moderate and respond to standard antimicrobial treatment 5, 6
• Treatment duration should be 7-14 days depending on severity and whether prostatitis can be excluded in men 4

When UTI Occurs

Treat UTIs promptly with appropriate antimicrobials based on culture results and local resistance patterns, but do not routinely discontinue Jardiance unless severe complications develop. 4, 1

• Discontinuation due to UTI was rare in clinical trials (0.1-0.2% of patients) 1, 5
• Consider temporarily discontinuing Jardiance if urosepsis or pyelonephritis develops 1
• For complicated UTIs with systemic symptoms, use combination therapy such as amoxicillin plus aminoglycoside or third-generation cephalosporin 4
• Manage any underlying urological abnormality that may be contributing to recurrent infections 4

For Recurrent UTIs on Jardiance

If a patient develops recurrent UTIs (≥2 episodes in 6 months or ≥3 in 12 months) while on Jardiance, implement non-antimicrobial preventive strategies first before considering drug discontinuation. 7, 8

• Increase fluid intake to reduce UTI risk 7, 8
• Recommend post-coital voiding 8
• For postmenopausal women, prescribe vaginal estrogen replacement 8
• Consider methenamine hippurate for prophylaxis in patients without urinary tract abnormalities 7, 8
• If non-antimicrobial measures fail, implement continuous or postcoital antimicrobial prophylaxis (nitrofurantoin 50-100 mg daily or based on culture results) 8

Critical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria in diabetic patients on Jardiance, as this fosters antimicrobial resistance without clinical benefit 4, 8
• Do not ignore urinary symptoms in elderly patients, as they may present atypically 4
• Do not continue Jardiance in patients with severe or recurrent urosepsis/pyelonephritis without addressing underlying causes 1
• Do not prescribe Jardiance to patients with significant bladder outlet obstruction until the obstruction is managed 3