I have diabetes and am taking Empagliflozin (Jardiance) but keep developing genital candidiasis; how should I treat and prevent these infections, and should I adjust my diabetes medication?

Managing Recurrent Genital Candidiasis While Taking Empagliflozin (Jardiance)

Continue your empagliflozin therapy while treating each episode of genital candidiasis with standard antifungal therapy, as the cardiovascular and renal benefits of SGLT2 inhibitors substantially outweigh the increased risk of these typically mild, easily treatable infections. 1, 2

Understanding the Risk

Genital mycotic infections occur in approximately 6% of patients taking SGLT2 inhibitors compared to only 1% on placebo, representing the most common genitourinary adverse effect of this drug class. 1, 2 These infections are typically mild to moderate in severity, respond well to brief antifungal courses, and rarely recur after treatment. 2, 3 The mechanism relates to glucosuria (glucose in urine) creating a favorable environment for yeast growth. 3, 4

Treatment of Active Infections

First-Line Antifungal Therapy

For each episode of genital candidiasis, use standard topical or oral antifungal treatment:

• Oral fluconazole 150 mg as a single dose is highly effective for uncomplicated vulvovaginal candidiasis, achieving >90% response rates 5
• Topical azole creams (clotrimazole, miconazole, terconazole) applied intravaginally for 3-7 days are equally effective alternatives 5
• Most infections respond to standard antimicrobial treatment without requiring empagliflozin discontinuation 3

When to Continue Empagliflozin

Do not discontinue empagliflozin for mild to moderate genital infections. 1, 6 Continue the medication during antifungal treatment, as these infections are clinically manageable and rarely lead to treatment discontinuation. 3, 7

When to Consider Temporary Discontinuation

Consider temporarily holding empagliflozin only in these specific situations:

• Severe genital infections requiring systemic therapy 1
• Fournier's gangrene (necrotizing fasciitis of the perineum)—this is a medical emergency requiring immediate discontinuation, urgent surgical debridement, and broad-spectrum antibiotics 5, 1
• Recurrent infections (≥4 episodes within one year) that significantly impact quality of life 5

Prevention Strategies

Patient Education and Hygiene

Implement these preventive measures before and during SGLT2 inhibitor therapy:

• Counsel on proper genital hygiene practices including keeping the genital area clean and dry 1, 2
• Educate about early symptoms (itching, burning, abnormal discharge) to facilitate prompt treatment 1
• Maintain adequate hydration to help reduce infection risk 1

For Recurrent Infections (≥4 Episodes/Year)

If you develop recurrent vulvovaginal candidiasis while on empagliflozin:

• Induction therapy: Use topical azole or oral fluconazole for 10-14 days 5
• Maintenance therapy: Follow with fluconazole 150 mg weekly for 6 months, which achieves symptom control in >90% of patients 5
• After completing maintenance therapy, expect a 40-50% recurrence rate, at which point you may need to reassess continuing empagliflozin 5

When to Consider Switching Diabetes Medications

Reassess Risk-Benefit Ratio

Permanent discontinuation of empagliflozin should be reserved for severe or frequently recurrent infections that significantly impair quality of life. 1 The decision requires weighing the substantial cardiovascular mortality reduction (35% decrease in heart failure hospitalization) and renal protection against the burden of recurrent infections. 5

Alternative Diabetes Medications

If you must discontinue empagliflozin due to recurrent infections, consider these alternatives:

• GLP-1 receptor agonists (dulaglutide, liraglutide, semaglutide) provide cardiovascular benefits without increasing genitourinary infection risk 1
• DPP-4 inhibitors (linagliptin, sitagliptin) are safe alternatives with no increased infection risk 1
• Metformin remains appropriate if your eGFR is ≥30 mL/min/1.73 m² 1

No Difference Between SGLT2 Inhibitors

There are no significant differences in genital mycotic infection rates between empagliflozin, dapagliflozin, and canagliflozin, so switching to another SGLT2 inhibitor will not reduce your infection risk. 1

Special Considerations

Diabetes Control

Optimize your glycemic control, as better blood sugar management may reduce the severity and frequency of fungal infections. 8 However, the glucosuria induced by empagliflozin is independent of your overall diabetes control. 3

Immunocompromised Status

If you are immunocompromised (including kidney transplant recipients), you require more careful monitoring for infections while on SGLT2 inhibitors. 1, 2

Sick Day Protocol

Temporarily hold empagliflozin during acute illness with reduced oral intake, prolonged fasting, or before surgery to reduce the risk of ketoacidosis and other complications. 1, 2 Resume after complete recovery.

Common Pitfalls to Avoid

• Do not discontinue empagliflozin prematurely for a single episode of mild genital infection—treat the infection and continue the medication 1, 6
• Do not confuse symptoms of euglycemic ketoacidosis (nausea, vomiting, abdominal pain) with genitourinary infection 1
• Do not ignore severe symptoms such as fever, systemic illness, or rapidly spreading perineal pain, which may indicate Fournier's gangrene requiring emergency care 5, 1
• Do not assume urinary tract infections are increased—large trials show no difference in UTI rates between SGLT2 inhibitors and placebo 2