Management of SGLT2 Inhibitor-Associated UTIs in an Older Adult with Type 2 Diabetes
For this 80-kg older adult who developed UTIs on an SGLT2 inhibitor, treat the active infection with standard antimicrobial therapy while continuing the SGLT2 inhibitor, then resume it after infection resolution—only discontinue permanently if severe or recurrent infections occur. 1
Understanding the UTI Risk with SGLT2 Inhibitors
The evidence regarding SGLT2 inhibitors and UTI risk is mixed, requiring careful interpretation:
- Large cardiovascular outcome trials (EMPA-REG OUTCOME, CANVAS, CANVAS-R) demonstrated no increased UTI risk compared to placebo despite millions of patient-years of exposure 2
- However, real-world observational data shows conflicting results, with some studies reporting increased UTI incidence (33.49% vs 11.72% in non-users, with 3.70-fold higher risk) 3, while others found no statistical difference 4
- The key distinction: genital mycotic infections (6% vs 1% placebo) are the primary genitourinary concern, not UTIs 5, 1
Risk Factors in This Patient
Your 80-kg older adult has specific risk factors that warrant attention:
- Older age consistently increases UTI susceptibility in SGLT2 inhibitor users 2, 3
- Male gender with potential bladder outlet obstruction (common in older men) may increase risk 6
- Evaluate for urinary retention or incomplete bladder emptying, as postvoid residual volumes >180 mL combined with SGLT2 inhibitors significantly increase infection risk 6
Management Algorithm
For Current UTI Episode:
- Continue the SGLT2 inhibitor during treatment of mild-to-moderate UTI with standard antimicrobial therapy 1
- Consider temporary discontinuation only if the UTI is severe or recurrent 1
- Most infections are mild-to-moderate and respond to standard treatment 7
Assessment for Underlying Risk Factors:
- Obtain renal ultrasound to assess postvoid residual volume and evaluate for bladder outlet obstruction 6
- Check HbA1c and BMI, as higher values predict increased UTI likelihood 4
- Review duration of diabetes, as longer disease duration increases infection risk in SGLT2 inhibitor users 4
Decision Points for Continuing SGLT2 Inhibitor:
Continue SGLT2 inhibitor if:
- First UTI episode with complete resolution after treatment 1
- No evidence of bladder outlet obstruction or urinary retention 6
- Significant cardiovascular or kidney disease where SGLT2 inhibitor benefits (35% reduction in ESRD/dialysis risk) outweigh infection risk 8
Permanently discontinue SGLT2 inhibitor if:
- Recurrent UTIs (≥2 episodes) despite optimal hygiene and infection management 1
- Severe infection requiring hospitalization 1
- Postvoid residual >180 mL or documented bladder outlet obstruction 6
- Patient develops septicemia related to UTI 6
Alternative Antihyperglycemic Options
If SGLT2 inhibitor discontinuation is necessary:
- GLP-1 receptor agonists (dulaglutide, liraglutide, semaglutide) require no dose adjustment and provide cardiovascular benefits without UTI risk 5
- Consider metformin if eGFR ≥30 mL/min/1.73 m² (reduce to 1000 mg/day if eGFR 30-44) 5
- DPP-4 inhibitors (linagliptin requires no dose adjustment) are safe alternatives 5
Prevention Strategies if Continuing SGLT2 Inhibitor
- Counsel on proper genital hygiene and adequate hydration 5, 1
- Educate about early UTI symptoms for prompt treatment 1
- Monitor for urinary retention symptoms: hesitancy, weak stream, incomplete emptying 6
- Reassess risk-benefit ratio at routine follow-up visits 1
Critical Caveats
- The cardiovascular mortality reduction and kidney disease progression benefits substantially outweigh tolerability issues in most patients 9
- Do not confuse euglycemic ketoacidosis symptoms with UTI 1
- Maintain at least low-dose insulin if patient is insulin-requiring to mitigate ketoacidosis risk 5
- Consider withholding SGLT2 inhibitor during acute illness, prolonged fasting, or surgery 5, 1
- In patients with CKD (eGFR ≥20 mL/min/1.73 m² with albuminuria ≥200 mg/g or heart failure), the strong recommendation for SGLT2 inhibitor use (1A evidence) means infection risk alone rarely justifies discontinuation 5