Fatal Taint Infection

Fatal Taint Infection just sounds like a punchline, but for diabetic people reading the fine print on their prescription information, it probably doesn’t seem particularly funny!

Diabetes is extremely common, affecting 10% of the adult population. By age 65, almost 30% of people will require medication for diabetes so pay attention, this may apply to you! There are also studies showing a 1% risk of developing diabetes after COVID infection, so diabetes is likely to become even more common.

Effective treatment is absolutely essential. Under-treated diabetes destroys your nerves and leads to blindness, chronic pain and amputation. It’s like leprosy for the modern age. In Canada, 60% of people on dialysis are diabetics because the disease also destroys your kidneys. It also increases your risk of heart disease and stroke. Stop your meds entirely and you can end up in a coma.

From a physician's perspective, achieving blood sugar control is arguably the most useful intervention you can offer your patients. Typically, only half of patients achieve good blood sugar control. This is likely due to a combination of poor diet, the cost of medications, and reluctance to accept that they have a chronic illness.

There has been a revolution in medications to control diabetes since I went to med school. Back then, we had metformin and glyburide, and if you failed those, you went on insulin. Now, there are regularly medications I don’t even recognize on my patients’ charts. Current options for diabetes care include metformin, GLP-1 RA, and SGLT2I with ASA, ACEI-ARD, and a statin added on for cardiovascular risk. In each of those categories there are a handful of brand-names that each have slightly different characteristics. You have so many options!

You’ve definitely heard of the GLP-1 receptor agonists: Ozempic, Rybelsus, Wegovy, Victoza, Saxenda, Trulicity and Mounjaro. They stimulate the pancreas to release more insulin when blood sugar levels are high, thus bringing sugars down. They also lower levels of glucagon, a hormone that raises blood sugar. They slow down digestion, smoothing blood sugar spikes, and decrease food seeking behaviour. They are kind of a big deal, showing a 12% reduction in all-cause mortality for people with diabetes. Ozempic is currently free for Ontario seniors who need it for optimal blood sugar control. It’s not currently on the list of meds that will be covered by Canadian pharmacare, but that may change as we get even more evidence about its effectiveness in preventing expensive complications of diabetes

The meds I see most often are the SGLT2 inhibitors: Invokana, Farxiga, Jardiance, Glyxambi, and Steglatro. They’re also sold as 2-in-1 meds, often combined with Metformin: Glyxambi, Synjardy, Xigduo, and Farxiga. They are even more impressive than GLP-1s, reducing all-cause mortality by 14%. Their mechanism of action is increasing the amount of sugar excreted in the urine, and generally people do really well on them with side effects being related to increased thirst and urinary frequency. 

I see these folks for one very specific reason. Rarely, and sometimes months after starting these medications, that lovely sugary urine leads to colonization of the peri-urethral area with candida. In layman’s terms: yeast around the peehole. [Apologies to my friend Jeana if she’s reading this; she hates the word peehole.  Not everyone knows what a urethra is!!] These folks tell me they have itching so severe they want to rip their vulva off. When their family docs do vaginal swabs for yeast, swabs are negative because the yeast isn’t in the vagina, it’s in the urethra. There are only two solutions to this problem: stop the medication, or take pills weekly to prevent yeast for as long as you take the med. 

So what’s this about Fatal Taint Infection? It is more commonly known as Fournier’s gangrene, and it’s listed as a possible adverse event in patients taking SGLT2 inhibitors. It’s basically Flesh-Eating Disease, but we give it a separate name when it’s in the crotch. Diabetics are at baseline higher risk, as high blood sugar impairs white blood cells and creates an environment where bacteria thrive. These bacteria usually don’t cause problems, and no one knows why they sometimes go rogue and inflict this deadly disease. 

The symptoms are intense genital pain and swelling, and the diagnosis is made on CT scan. It’s a true surgical emergency with a 20% mortality rate. We get about 9 a year at our hospital with a catchment of 800,000 people. Weirdly, they always come in 3s. We’ll get 3 cases within a couple of weeks, then none for months, and then 3 again.

You’ll be happy to know that we haven’t seen a noticeable increase in Fournier’s Gangrene cases since the SGLT2 inhibitors came into widespread use. The good news is, I don’t think you need to lose any sleep over that particular piece of fine print. If you’re a diabetic, these medications are far more likely to save your life, your sight, your kidneys, and your limbs than they are to cause you harm. You’ll want to work closely with your doctor, perhaps even with a Diabetes Coach, and invest in a home blood sugar monitor to optimize your blood sugar control and your well-being.