Management of Fungal Infections in Patients Taking SGLT2 Inhibitors

Introduction to Fungal Infections

The use of SGLT2 inhibitors can increase urinary glucose excretion, creating favorable conditions for fungal growth in the genital region, leading to infections such as candidiasis in patients taking these medications 1

Consider discontinuing SGLT2 inhibitors if clinically appropriate to address the underlying cause of the fungal infection, as recommended by the Clinical Infectious Diseases guideline 1
If SGLT2 inhibitors must be continued, implement more aggressive antifungal therapy to manage the infection 1

For patients with fluconazole-resistant cases, consider alternative oral antifungals, such as those recommended by the Clinical Infectious Diseases guideline 1
The American College of Physicians recommends first-line treatment with topical emollients and moisturizers, and consideration of topical low-potency corticosteroids for localized areas 2, 3

Oral antihistamines, such as cetirizine or diphenhydramine 25-50 mg orally every 6 hours as needed, can be used for itch relief in patients with fungal infections 1, 2, 3
The combination of H1 and H2 blockers shows better efficacy than either agent alone, with a relative risk of 1.59 (95% CI 1.07 to 2.36) for resolution of urticaria 4
Adding famotidine to diphenhydramine improves resolution of urticaria 4

Keeping the affected area clean and dry, using soap-free cleansers, and wearing loose-fitting cotton underwear can help reduce moisture and prevent fungal growth 1

Patients should be instructed to continue treatment for 1-2 weeks after visible resolution to prevent recurrence of the fungal infection 1
If no improvement is seen within 2 weeks, consider oral fluconazole 200mg once weekly for 2-4 weeks, as recommended by the Clinical Infectious Diseases guideline 1
Reassess after 2 weeks or if symptoms worsen, as per the Annals of Oncology guidelines 5
For inadequate response, consider adding famotidine 20 mg twice daily to enhance antihistamine effect, and short-term topical steroids of moderate potency, as recommended by the Annals of Oncology 5
If still inadequate, consider a short course of oral prednisone (20 mg twice daily for 4 days) 5
Oral steroids should be limited to short courses (typically 3-7 days) for acute rashes to avoid systemic side effects, including immunosuppression, hyperglycemia, and adrenal suppression, as recommended by the Annals of Oncology 3

Warn patients about driving and operating machinery due to sedation with diphenhydramine 3
Monitor for signs of secondary infection that may require antibiotics, as per the Journal for ImmunoTherapy of Cancer guidelines 6
The American Academy of Dermatology suggests withholding any potential causative medications, oral prednisone 0.5-1 mg/kg daily for 3-7 days with taper over 1-2 weeks, diphenhydramine 50 mg every 6 hours, and famotidine 20 mg twice daily, with close follow-up within 48-72 hours to assess response 3