From the Guidelines
Finerenone can cause hyperkalemia (elevated serum potassium levels) as a significant side effect, with a higher incidence of hyperkalemia in the finerenone group, 10.8% vs. 5.3%, as reported in the FIDELITY prespecified pooled efficacy and safety analysis 1. This non-steroidal mineralocorticoid receptor antagonist works by blocking aldosterone's effects, which normally promotes potassium excretion in the kidneys. When starting finerenone, patients should have their potassium levels checked before treatment, again at 4 weeks, and periodically thereafter. The risk of hyperkalemia is higher in patients with reduced kidney function, diabetes, and those taking other medications that raise potassium levels (such as ACE inhibitors, ARBs, or potassium supplements). Some key points to consider when using finerenone include:
- Typical dosing starts at 10 mg once daily for patients with eGFR ≥60 mL/min/1.73m², and 10 mg every other day for those with eGFR 25-60 mL/min/1.73m², as seen in the FIGARO-DKD study 1.
- If potassium levels rise above 5.0 mEq/L, dose reduction should be considered, and if levels exceed 5.5 mEq/L, finerenone should be temporarily discontinued until potassium normalizes.
- Patients should be counseled to avoid high-potassium foods and other potassium-raising medications while taking finerenone to minimize this risk. It's essential to monitor potassium levels closely, especially in patients with risk factors for hyperkalemia, to ensure safe use of finerenone and minimize the risk of adverse effects on serum potassium levels, as supported by the findings of the FIDELITY analysis 1.
From the Research
Effect of Finerenone on Serum Potassium Levels
- Finerenone, a mineralocorticoid receptor antagonist, has been shown to increase serum potassium levels in patients with chronic kidney disease (CKD) and type 2 diabetes 2, 3, 4, 5, 6.
- The increase in serum potassium levels is predictable and manageable with routine monitoring and hyperkalemia management strategies 2, 3, 5.
- Studies have reported that finerenone is associated with a higher risk of hyperkalemia (serum potassium > 5.5 mmol/L) compared to placebo 2, 4.
- However, the risk of hyperkalemia-related severe adverse events is low, and permanent discontinuation of finerenone due to hyperkalemia is rare 3, 5.
- Finerenone has been shown to reduce the risk of cardiorenal outcomes in patients with CKD and type 2 diabetes, despite the increased risk of hyperkalemia 2, 3, 5, 6.
Risk Factors for Hyperkalemia with Finerenone
- Higher serum potassium levels at baseline 2, 4
- Lower estimated glomerular filtration rate (eGFR) 2
- Increased urine albumin-creatinine ratio 2
- Younger age 2
- Female sex 2
- Use of beta-blockers 2
- Use of finerenone itself 2, 4
Management of Serum Potassium Levels with Finerenone
- Routine monitoring of serum potassium levels is recommended 2, 3, 5.
- Hyperkalemia management strategies, such as withholding the study drug until serum potassium levels decrease, can minimize the impact of hyperkalemia 2.
- Patients at risk of hyperkalemia can be identified early in clinical practice and monitored closely for easy management 3.