Empagliflozin

## What can go wrong **Genital mycotic infections** are the most common side effect, affecting 4-10% of users — yeast in women, balanitis in uncircumcised men. Usually responds to topical antifungals and does not require drug discontinuation. **Urinary tract infections** occur slightly more often than placebo. Most are uncomplicated. **Volume depletion** is meaningful — empagliflozin adds 200-400 mL/day of urinary loss. Combined with loop diuretics, hot weather, or vigorous exercise, this can produce hypotension or acute kidney injury. **Euglycemic diabetic ketoacidosis** is the most dangerous adverse event. DKA can occur with blood glucose under 200 mg/dL, delaying diagnosis. Risk concentrates during fasting, ketogenic diets, alcohol binges, illness, and surgery. Hold 3-4 days before major surgery and during prolonged fasts. Do not combine with ketogenic protocols without specialist supervision. **Fournier gangrene** (necrotizing fasciitis of the perineum) has been reported. Rare but devastating; any perineal pain, swelling, or fever demands urgent evaluation. **Lower-limb amputation** signal seen with canagliflozin in CANVAS does not appear strongly with empagliflozin but warrants attention in patients with peripheral artery disease. **Bone density** modest reductions have been reported with canagliflozin; signal is weaker for empagliflozin.