D1.103 - Successful Class Switching of SGLT2 Inhibitors Following Empagliflozin-Induced Maculopapular Exanthema: A Case Report

Sodium-glucose co-transporter 2 (SGLT2) inhibitors or gliflozins have become a cornerstone in the management of Type 2 diabetes, chronic kidney disease, and heart failure with reduced ejection fraction. While generally well-tolerated, cutaneous adverse drug reactions (cADRs) such as urticaria and bullous pemphigoid-like eruptions have been rarely reported. We present a case of a non-specific maculopapular rash induced by empagliflozin, successfully managed by switching to an alternative molecule within the same class.

A 37-year-old male was admitted for an extensive anterior myocardial infarction complicated by left ventricular failure. A secondary prevention regimen was initiated, comprising acetylsalicylic acid, clopidogrel, atorvastatin, ramipril, and empagliflozin. Shortly after initiation, the patient developed a diffuse, erythematous, and pruritic maculopapular eruption. Given the temporal correlation, empagliflozin was identified as the primary suspect and withdrawn, while other medications were maintained.Clinical resolution occurred promptly following the cessation of empagliflozin. According to the Naranjo adverse drug reaction probability scale, the causality was classified as "possible." Due to the therapeutic necessity of SGLT2 inhibitors for heart failure management, dapagliflozin was initiated. The switch was tolerated without recurrence of cutaneous symptoms.

Immune-mediated hypersensitivity reactions to gliflozins may be directed at the core chemical structure, leading to class-wide cross-reactivity, or toward a specific side chain unique to the molecule. This case suggests that in moderate hypersensitivity reactions, a cautious switch to a different SGLT2 inhibitor may be feasible when the clinical benefit outweighs the risk of recurrence.

Clinicians should remain vigilant for hypersensitivity reactions to SGLT2 inhibitors. While cross-reactivity is a theoretical risk, successful intra-class switching can preserve essential therapeutic options for patients with cardiovascular benefits. This case highlights the importance of recognizing hypersensitivity reactions to this drug class and discusses the nuanced considerations regarding cross-reactivity among gliflozins.