Is finerenone indicated for patients with type 1 diabetes and diabetic kidney disease, especially those already on an ACE inhibitor or ARB?

Finerenone is NOT Currently Indicated for Type 1 Diabetes

Finerenone is specifically recommended only for patients with type 2 diabetes (T2D) and chronic kidney disease with albuminuria, not for type 1 diabetes (T1D). The major guidelines explicitly limit their recommendations to T2D patients 1, 2.

Guideline-Based Recommendations

The 2022 KDIGO and ADA consensus guidelines are unequivocal in their restriction of finerenone to T2D:

• Consensus Statement: "An ns-MRA with proven kidney and cardiovascular benefit is recommended for patients with T2D, eGFR ≥25 ml/min/1.73 m², normal serum potassium concentration, and albuminuria (ACR ≥30 mg/g) despite maximum tolerated dose of RAS inhibitor" 2

• The guidelines consistently specify that finerenone should be added to treatment regimens of "patients with T2D who have any level of persistent albuminuria despite current standard of care treatment" 2

• All visual algorithms and treatment frameworks in the guidelines explicitly label finerenone recommendations as "T2D only" 1

Why This Distinction Matters

The evidence base for finerenone comes entirely from trials (FIDELIO-DKD and FIGARO-DKD) that enrolled only T2D patients. Until recently, there was no clinical trial data supporting finerenone use in T1D, which is why guidelines appropriately restricted recommendations to T2D.

Emerging Evidence for Type 1 Diabetes

Very recent data (2026) suggests finerenone may be effective in T1D, but this has not yet been incorporated into guidelines:

• The FINE-ONE trial 3 demonstrated that finerenone reduced albuminuria by 25% more than placebo in adults with T1D and CKD (urinary albumin-to-creatinine ratio decreased 34% vs 12% with placebo, P<0.001)
• Hyperkalemia occurred in 10.1% of finerenone patients vs 3.3% with placebo
• eGFR declined more with finerenone initially (-5.6 vs -2.7 ml/min/1.73 m²) but approached baseline during washout 3

A small retrospective study 4 showed finerenone stabilized eGFR decline in T1D patients over 6 months compared to controls, with no hyperkalemia or AKI events.

Current Clinical Approach for Type 1 Diabetes Patients

For T1D patients with diabetic kidney disease already on ACE inhibitors or ARBs:

1. Standard of care remains: ACE inhibitor or ARB titrated to maximum tolerated dose 1, 2

2. Finerenone is off-label for T1D at this time, as it lacks FDA approval and guideline endorsement for this population

3. If considering finerenone off-label based on the new FINE-ONE data 3:

   • Ensure eGFR ≥25 ml/min/1.73 m²
   • Baseline potassium must be ≤5.0 mmol/L
   • Persistent albuminuria (ACR ≥30 mg/g) despite maximized ACE inhibitor/ARB
   • Dose: 10 mg daily if eGFR 25-60; 20 mg daily if eGFR >60
   • Monitor potassium at 4 weeks after initiation and regularly thereafter
   • Withhold if potassium >5.5 mmol/L

Critical Caveats

• The FINE-ONE trial 3 was only 6 months in duration—long-term kidney and cardiovascular outcomes in T1D remain unknown
• The initial eGFR decline with finerenone requires careful monitoring and patient counseling
• Hyperkalemia risk is real: 10% incidence in the trial, requiring potassium monitoring infrastructure 3
• Combined use with ACE inhibitors/ARBs increases both efficacy and hyperkalemia risk 5

What Guidelines DO Recommend for T1D + CKD

For patients with T1D and diabetic kidney disease, current evidence-based therapy includes:

• ACE inhibitor or ARB (titrated to maximum tolerated dose) for those with hypertension and albuminuria 1, 2
• Statin therapy for all T1D patients with CKD 1, 2
• Intensive glycemic control
• Blood pressure target individualization with monitoring

The evidence for finerenone in T1D is promising but preliminary—expect guideline updates if longer-term outcome data confirm the FINE-ONE findings 3.