Management of Kerendia (Finerenone) Before CABG Surgery
The safety of continuing or holding Kerendia (finerenone) before CABG surgery is uncertain, as there is no specific guidance addressing this medication in perioperative CABG guidelines. However, based on the drug class and available evidence, a cautious approach is warranted.
Recommendation Based on Drug Class
Kerendia is a nonsteroidal mineralocorticoid receptor antagonist (MRA), which places it in the same functional category as ACE inhibitors and angiotensin receptor blockers (ARBs) regarding renin-angiotensin-aldosterone system (RAAS) modulation. The 2011 ACC/AHA CABG guidelines explicitly state that "the safety of the preoperative administration of ACE inhibitors or angiotensin-receptor blockers in patients on chronic therapy is uncertain" (Class IIb recommendation) 1.
Key Considerations for Holding Kerendia
Given the uncertain safety profile of RAAS inhibitors perioperatively and the known risks, it is reasonable to hold Kerendia 24-48 hours before CABG surgery. This recommendation is based on:
Hypotension Risk: RAAS inhibitors, including MRAs, are associated with intraoperative hypotension after anesthesia induction and a blunted response to pressors and inotropic agents 2
Vasoplegia Syndrome: ACE inhibitors and ARBs have been associated with severe hypotension after cardiopulmonary bypass (vasoplegia syndrome) and postoperative renal dysfunction 2
Pharmacokinetics: Finerenone reaches steady-state after 2 days of dosing, with a time to maximum concentration of 0.5-1 hour after oral administration 3. Holding the medication 24-48 hours preoperatively allows for clearance while minimizing perioperative complications
Practical Management Algorithm
Preoperative Phase:
- Check serum potassium within 24 hours before surgery (should be ≤5.0 mEq/L for safe surgery)
- Hold Kerendia 24-48 hours before scheduled CABG
- Monitor blood pressure closely during the holding period
- Ensure adequate hydration to prevent hypotension
Postoperative Phase:
Restart Kerendia once the patient is hemodynamically stable, typically 24-48 hours postoperatively, following the guideline recommendation that "ACE inhibitors and ARBs given before CABG should be reinstituted postoperatively once the patient is stable, unless contraindicated" 2. This same principle applies to finerenone as a RAAS modulator.
Important Caveats
- Do NOT discontinue statins before CABG, as this is explicitly contraindicated (Class III: HARM) 1
- Continue beta-blockers through surgery if the patient is already taking them, as they should be administered for at least 24 hours before CABG 1
- Coordinate with the surgical team regarding the timing of Kerendia discontinuation and reinitiation
- Monitor potassium levels closely both pre- and postoperatively, as hyperkalemia is the most common adverse event with finerenone (8% incidence in real-world data) 4
The absence of specific guidance for finerenone in CABG guidelines necessitates extrapolation from the known risks of other RAAS inhibitors, making a cautious approach of temporary discontinuation the most prudent strategy to minimize perioperative complications while preserving long-term cardiorenal protection.