Should SGLT2 Inhibitors Be Withdrawn in Balanoposthitis?
SGLT2 inhibitors should NOT be withdrawn in this patient with balanoposthitis and a normal urine examination; instead, treat the infection with standard antifungal therapy while continuing the SGLT2 inhibitor. 1, 2
Rationale for Continuing SGLT2 Inhibitors
The cardiovascular and renal benefits of SGLT2 inhibitors substantially outweigh the risk of genital mycotic infections in most patients with diabetes. 1, 2 Balanoposthitis in diabetic men is most commonly caused by Candida, and the mainstay of treatment is maintenance of hygiene, glycemic control, and eradication of infection—not drug withdrawal. 3
Most genital mycotic infections can be treated with standard antifungal therapy without discontinuing the SGLT2 inhibitor. 1, 4 The normal urine routine examination in this case suggests a localized genital infection rather than a systemic or urinary tract infection, making continuation of therapy even more appropriate. 2
Management Algorithm
Immediate Management
- Initiate standard topical or oral antifungal therapy (e.g., clotrimazole cream or fluconazole) for the balanoposthitis 1, 4
- Continue SGLT2 inhibitor during treatment of this mild to moderate infection 1, 4
- Counsel on proper genital hygiene to prevent recurrence 1, 4
- Optimize glycemic control as hyperglycemia predisposes to recurrent infections 3
When to Consider Temporary Discontinuation
Temporarily discontinue SGLT2 inhibitor ONLY if: 1, 4
- The infection is severe (extensive tissue involvement, systemic symptoms)
- The infection recurs despite adequate antifungal treatment
- Signs of Fournier's gangrene develop (requires immediate discontinuation and urgent surgical consultation) 1, 4
When to Resume Therapy
- Resume SGLT2 inhibitor after complete resolution of the infection if it was temporarily discontinued 1
- For mild infections treated without discontinuation, continue therapy throughout treatment 1, 4
Evidence Supporting Continuation
SGLT2 inhibitors are associated with approximately a 3-fold increased risk of genital infections (6% vs 1% on placebo), but these infections are typically mild and respond well to brief antifungal courses. 5, 6 The excess risk is 11.9 per 1000 person-years in men—a relatively small absolute risk increase. 5
The benefits of SGLT2 inhibitors on kidney and cardiovascular outcomes generally outweigh the risk of genitourinary infections in most patients. 1, 2 In patients with chronic kidney disease, heart failure, or high cardiovascular risk, the mortality and morbidity benefits are substantial and should not be sacrificed for a treatable local infection. 7
Important Caveats
Monitor for Recurrence
- Reassess the risk-benefit ratio if infections become recurrent (≥3 episodes) 1, 4
- Consider permanent discontinuation only if infections are severe, recurrent, or significantly impact quality of life 1
Distinguish from Other Complications
- Do not confuse with euglycemic ketoacidosis, which presents with systemic symptoms (nausea, vomiting, abdominal pain, malaise) rather than isolated genital symptoms 1
- The normal urine examination makes urinary tract infection or ketoacidosis unlikely 2
Patient Education
- Provide education on early symptom recognition to facilitate prompt treatment of future episodes 1, 4
- Emphasize that proper hygiene and glycemic control reduce recurrence risk 1, 3
- Advise seeking urgent medical attention only if severe symptoms develop (extensive swelling, fever, systemic illness) 1
Special Consideration for This Patient
Given this patient's age (50s) and diabetes requiring SGLT2 inhibitor therapy, he likely has cardiovascular risk factors or chronic kidney disease that prompted SGLT2 inhibitor initiation. 7 Withdrawing the SGLT2 inhibitor for a treatable local infection would eliminate proven mortality and morbidity benefits without addressing the underlying infection. 1, 2