What is the best approach to manage recurrent urinary tract infections (UTIs) in an elderly patient with diabetes who recently started taking Farxiga (dapagliflozin)?

Management of Recurrent UTIs in an Elderly Patient on Farxiga (Dapagliflozin)

You should strongly consider discontinuing Farxiga in this elderly patient experiencing recurrent UTIs, as SGLT2 inhibitors like dapagliflozin increase UTI risk through drug-induced glucosuria, and the FDA specifically warns that caution should be used in people with recurrent or severe urinary tract infections. 1, 2

Understanding the Drug-Related Risk

The FDA label for dapagliflozin explicitly states that "serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization have been reported in patients receiving SGLT2 inhibitors, including dapagliflozin" and that "treatment with SGLT2 inhibitors increases the risk for urinary tract infections." 2 The 2025 American Diabetes Care guidelines specifically note that SGLT2 inhibitors "are associated with a small increase in urinary tract infections" and recommend "caution should be used in people with recurrent or severe urinary tract infections." 1

Key mechanistic considerations:

• SGLT2 inhibitors cause glucosuria (glucose in urine), which creates a favorable environment for bacterial growth 3, 4
• Research shows UTI rates of 4.3-5.7% with dapagliflozin versus 3.7% with placebo 4
• The 10 mg dose shows higher urinary frequency (55%) and urgency (48%) compared to 5 mg dose (~25% and ~20% respectively) 3
• Most UTIs occur within the first 24 weeks of therapy but can persist throughout treatment 5

Immediate Clinical Actions

Evaluate for additional risk factors in this elderly patient:

• Assess for bladder outlet obstruction - particularly critical in males, as case reports document severe E. coli septicemia in men with incomplete bladder emptying on dapagliflozin 6
• Check post-void residual volume - volumes >180 mL significantly increase UTI risk with SGLT2 inhibitors 6
• Evaluate for urinary incontinence - present in 75% of women aged 75 years and worsened by SGLT2 inhibitor-induced increased urine volume 1, 7
• Review for atrophic vaginitis in postmenopausal women - a major modifiable risk factor 7, 8
• Assess functional status and frailty - elderly patients are at higher risk for volume depletion and complications 1

Confirm true UTI versus asymptomatic bacteriuria:

• Do NOT treat asymptomatic bacteriuria - present in 15-50% of elderly women, treatment does not improve outcomes and increases antibiotic resistance 1, 7
• Require BOTH clinical symptoms AND positive urine culture before diagnosing UTI 1, 7
• A negative dipstick for both nitrite AND leukocyte esterase strongly excludes UTI (though specificity is only 20-70% in elderly) 1, 7
• Watch for atypical presentations: confusion, functional decline, fatigue, or falls rather than classic dysuria 1, 9

Treatment Algorithm for Current UTI

If the patient has a confirmed symptomatic UTI right now:

1. Obtain urine culture with susceptibility testing before starting antibiotics 7, 9

2. Initiate empiric therapy based on local resistance patterns:

   • First-line options: Fosfomycin 3g single dose, nitrofurantoin 100mg twice daily for 5 days, or pivmecillinam 400mg three times daily for 3-5 days 7
   • Alternative: Trimethoprim-sulfamethoxazole 160/800mg twice daily only if local E. coli resistance <20% 7
   • Avoid fluoroquinolones as first-line due to resistance and adverse effects in elderly 7

3. Adjust antibiotics once culture results return 7, 8

Decision Point: Continue or Discontinue Farxiga?

Strongly consider DISCONTINUING dapagliflozin if:

• Recurrent UTIs continue despite appropriate antibiotic treatment 1, 2
• Patient has bladder outlet obstruction or elevated post-void residual 6
• UTIs are severe (requiring hospitalization, urosepsis, pyelonephritis) 2
• Patient is frail with multiple comorbidities and polypharmacy 1
• The cardiovascular/renal benefits do not clearly outweigh infection risk in this specific patient 1

May consider CONTINUING dapagliflozin with close monitoring if:

• Strong cardiovascular or renal indication exists (heart failure, CKD) where benefits clearly outweigh risks 1
• UTIs are mild, infrequent, and easily managed 4, 5
• Modifiable risk factors can be addressed (see prevention strategies below) 7
• Consider dose reduction from 10mg to 5mg if glycemic control allows, as lower doses show reduced urinary symptoms 3

Prevention Strategies if Continuing SGLT2 Inhibitor

If you decide the cardiovascular/renal benefits justify continuing dapagliflozin despite UTI risk:

Primary prevention interventions:

• Vaginal estrogen therapy for postmenopausal women (≥850 µg weekly) - the most effective prevention strategy with high-quality evidence 7, 8
• Methenamine hippurate 1g twice daily - non-antibiotic prophylaxis that releases formaldehyde in acidic urine, non-inferior to antibiotic prophylaxis 7, 9
• Immunoactive prophylaxis (OM-89 E. coli bacterial lysate) - strongly recommended for all age groups 7, 9

Behavioral modifications:

• Increase fluid intake and maintain adequate hydration 9
• Implement timed voiding schedules to prevent urinary retention 7
• Pelvic floor exercises if appropriate 7

Reserve for refractory cases only:

• Continuous low-dose antibiotic prophylaxis (trimethoprim-sulfamethoxazole or nitrofurantoin) for 6-12 months only when non-antimicrobial interventions have failed 7, 9

Critical Monitoring Parameters

If continuing dapagliflozin:

• Monitor for volume depletion - elderly patients on loop diuretics are at increased risk for hypotension and acute kidney injury 1, 2
• Assess renal function regularly - dapagliflozin increases risk of volume depletion-related AKI 2
• Watch for genital mycotic infections - occur in 7.4-14.3% of patients and may be burdensome enough to require discontinuation 1, 2, 5
• Educate on signs of serious complications: Fournier's gangrene (perineal pain, erythema, swelling with fever), urosepsis (fever, rigors, hemodynamic instability) 2

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria just because urine culture is positive - this is extremely common in elderly patients and treatment causes harm without benefit 1, 7
• Do not assume all urinary symptoms are UTI - SGLT2 inhibitors cause urinary frequency and urgency from osmotic diuresis independent of infection 1, 3
• Do not ignore bladder outlet obstruction - this dramatically increases UTI risk with SGLT2 inhibitors and can lead to severe sepsis 6
• Do not continue dapagliflozin indefinitely if recurrent UTIs persist - the drug is likely contributing to the problem 1, 2
• Account for polypharmacy and drug interactions when selecting antibiotics in elderly patients 7, 9