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Abstract

We thank Michael Balkin for his interest in our article.1Kawahigashi T Kawabe T Iijima H et al.Beware of perianal pain: Fournier gangrene.Am J Med. 2020; 133: 924-925Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar He made an important point about our case: The use of sodium glucose cotransporter-2 (SGLT2) inhibitors may be associated with the development of Fournier gangrene.2Stover KR Hugh E Sherman JJ Malinowski SS et al.Infectious complications of newer agents in the fight against diabetes.Nurse Pract. 2020; 45: 17-24Crossref Scopus (1) Google Scholar It is worthwhile to mention that diabetes is one of the most common comorbid risk factors for Fournier gangrene and the use of SGLT2 inhibitors for type 2 diabetes mellitus is increasing each year because of the significant cardiovascular benefit of SGLT2 inhibitors in people with type 2 diabetes.3Zou CY Liu XK Sang YQ Wang B Liang J Effects of SGLT2 inhibitors on cardiovascular outcomes and mortality in type 2 diabetes: a meta-analysis.Medicine (Baltimore). 2019; 98: e18245Crossref Scopus (22) Google Scholar In August 2018, the Food and Drug Administration (FDA) issued a warning regarding the occurrence of Fournier gangrene. A recent review of the Food and Drug Administration and case reports identified 55 cases of Fournier gangrene among patients receiving SGLT2 inhibitors between 2013 and 2019, compared with 19 cases among patients receiving all other antihyperglycemics between 1984 and 2019.1Kawahigashi T Kawabe T Iijima H et al.Beware of perianal pain: Fournier gangrene.Am J Med. 2020; 133: 924-925Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Fortunately, our patient did not receive an SGLT2 inhibitor; instead, he was treated with teneligliptin hydrobromide hydrate, a dipeptidyl peptidase 4 (DPP-4) inhibitor. Although his type 2 diabetes mellitus was well controlled by the DPP-4 inhibitor (his hemoglobin A1c on admission was 6.9%), his Fournier gangrene would be associated with type 2 diabetes mellitus. DPP-4 inhibitors may pose a lower risk for adverse events such as urinary and urogenital tract infections than do SGLT2 inhibitors. However, further examinations are needed because some previous reports demonstrate that the use of SGLT2 inhibitors showed a similar risk of urinary tract infections among different second-line antidiabetic medications, DPP4 inhibitors, and glucagon-like peptide 1 agonists.4Dave CV Schneeweiss S Kim D et al.Sodium-glucose cotransporter-2 inhibitors and the risk for severe urinary tract infections: a population-based cohort study.Ann Intern Med. 2019; 171: 248-256Crossref Scopus (51) Google Scholar In our case, SGLT-2 inhibitors did not contribute to Fournier gangrene; however, clinicians should be aware of the risks of SGLT-2 inhibitors in patients with comorbid risk factors for Fournier gangrene. Be Vigilant About Perianal PainThe American Journal of MedicineVol. 134Issue 3PreviewThe Diagnostic Dilemma reported by Kawahigashi et al is particularly timely in view of the increasing use of sodium glucose cotransporter 2 (SGLT2) inhibitors for diabetes and heart failure.1,2 Many of us are learning for the first time about Fournier gangrene and its relationship to SGLT2 inhibitors.3 We have now become more vigilant about questioning and evaluating our diabetic patients for perianal symptoms. Although there would appear to be no relationship to medication usage and the development of an abscess in what the authors described as a long-standing mass, given the evolving knowledge of Fournier gangrene we must be explicitly informed as to whether the patient was exposed to an SGLT2 inhibitor. Full-Text PDF