Is adding finerenone to the regimen of a patient with type 2 diabetes (T2D), chronic kidney disease (CKD), and impaired renal function, who is already taking canagliflozin (Sodium-Glucose Cotransporter 2 inhibitor), appropriate for additional kidney protection?

From the Guidelines

Adding finerenone to the current regimen is appropriate to help slow the progression of kidney disease in this patient. According to the ADA and KDIGO consensus report, finerenone is recommended for patients with type 2 diabetes, CKD, elevated albuminuria (UACR ≥30 mg/g), and eGFR ≥25 mL/min/1.73 m² [ 1 ]. This patient meets these criteria with an eGFR of 35 mL/min/1.73 m² and UACR of 50 mg/g. The patient's serum potassium of 4.5 mEq/L is within normal range and does not contraindicate finerenone use, though potassium levels should be monitored after initiation [ 1 ].

Key Points to Consider

• Finerenone provides complementary kidney protection through different mechanisms than SGLT2 inhibitors like canagliflozin [ 1 ].
• While canagliflozin primarily works by reducing glomerular hyperfiltration, finerenone reduces inflammation and fibrosis in the kidney [ 1 ].
• Using both medications together provides additive kidney protection benefits and is supported by clinical evidence showing that the combination can further reduce the risk of CKD progression and cardiovascular events compared to either agent alone [ 1 ].

Clinical Evidence

The FIDELIO-DKD and FIGARO-DKD trials have demonstrated the efficacy of finerenone in reducing the risk of CKD progression and cardiovascular events in patients with type 2 diabetes and CKD [ 1 ]. The ADA and KDIGO consensus report recommends the use of finerenone in patients with type 2 diabetes, CKD, and elevated albuminuria, making it an appropriate addition to this patient's treatment regimen [ 1 ].

From the FDA Drug Label

The CREDENCE trial was a multinational, randomized, double-blind, placebo-controlled trial comparing canagliflozin with placebo in adult patients with type 2 diabetes mellitus, an eGFR ≥ 30 to < 90 mL/min/1. 73 m 2and albuminuria (urine albumin/creatinine > 300 to ≤ 5,000 mg/g) who were receiving standard of care including a maximum-tolerated, labeled daily dose of an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) Canagliflozin 100 mg significantly reduced the risk of the primary composite endpoint based on a time-to-event analysis [HR: 0.70; 95% CI: 0.59,0.82; p<0. 0001]

The patient's eGFR is 35 mL/min/1.73 m2, which is within the range of the CREDENCE trial (eGFR ≥ 30 to < 90 mL/min/1.73 m2). Adding finerenone to the current regimen is not directly addressed in the provided drug label. However, considering the patient is already on canagliflozin, an SGLT2 inhibitor, the potential benefit of adding finerenone should be weighed against the potential risks, including the risk of hyperkalemia.

• The patient's serum potassium level is 4.5 mEq/L, which is within the normal range.
• The patient's urine albumin-to-creatinine ratio (UACR) is 50 mg/g, indicating albuminuria. No conclusion can be drawn regarding the use of finerenone in this patient based on the provided drug label 2.

From the Research

Finerenone Use in Patients with Chronic Kidney Disease and Type 2 Diabetes

• The use of finerenone in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) has been studied in several clinical trials 3, 4, 5, 6, 7.
• Finerenone is a nonsteroidal mineralocorticoid receptor antagonist that has been shown to reduce the risk of kidney and cardiovascular events in patients with CKD and T2D 5, 7.
• The FIDELIO-DKD and FIGARO-DKD studies demonstrated that finerenone significantly reduced the composite endpoints of kidney failure, sustained decrease in eGFR, and renal death, as well as cardiovascular events, compared to placebo 5, 7.
• The use of finerenone in combination with sodium-glucose cotransporter 2 inhibitors (SGLT2is) has also been evaluated, and the results suggest that finerenone provides additional kidney benefits beyond those provided by SGLT2is alone 5, 7.
• The FIDELITY analysis, a prespecified pooled analysis of the FIDELIO-DKD and FIGARO-DKD studies, found that finerenone reduced the risk of kidney and cardiovascular events in patients with CKD and T2D, regardless of whether they were taking an SGLT2i or not 7.
• The safety profile of finerenone has been evaluated in several studies, and the results suggest that finerenone is generally well-tolerated, with a low risk of hyperkalemia compared to other mineralocorticoid receptor antagonists 4, 6.

Considerations for Use in the Presented Patient

• The patient has a history of CKD, T2D, and is currently taking canagliflozin, an SGLT2i.
• The patient's eGFR is 35 mL/min/1.73 m2, and their urine albumin-to-creatinine ratio (UACR) is 50 mg/g.
• Based on the available evidence, adding finerenone to the patient's current regimen may be appropriate to help slow the progression of kidney disease, as finerenone has been shown to provide additional kidney benefits beyond those provided by SGLT2is alone 5, 7.
• The patient's serum potassium level is 4.5 mEq/L, which is within the normal range, and the risk of hyperkalemia with finerenone is generally low 4, 6.
• The patient's eGFR is not a contraindication to the use of finerenone, as the FIDELIO-DKD and FIGARO-DKD studies included patients with eGFR as low as 25 mL/min/1.73 m2 5, 7.