What is Kerendia (finerenone) used for?

Kerendia (Finerenone) Uses in Clinical Practice

Kerendia (finerenone) is primarily used to reduce the risk of kidney function decline, kidney failure, cardiovascular death, non-fatal heart attacks, and hospitalization for heart failure in adults with chronic kidney disease (CKD) associated with type 2 diabetes. 1

Mechanism and Clinical Benefits

Finerenone is a selective non-steroidal mineralocorticoid receptor antagonist (MRA) that works differently from traditional therapies by:

• Directly targeting inflammation and fibrosis pathways in the kidneys and heart
• Blocking overactivation of mineralocorticoid receptors that contribute to CKD progression
• Providing both renal and cardiovascular protection in patients with type 2 diabetes

Specific Indications

Finerenone is indicated for patients with:

• Type 2 diabetes with chronic kidney disease
• Albuminuria (UACR ≥30 mg/g)
• eGFR range of 25-90 mL/min/1.73 m²
• Patients already on maximum tolerated dose of renin-angiotensin system inhibitors (ACE inhibitors or ARBs)

Clinical Trial Evidence

Two major trials support finerenone's effectiveness:

1. FIDELIO-DKD trial: Demonstrated significant reduction in:

   • Primary composite kidney outcome (kidney failure, sustained decrease ≥40% in eGFR, or death from kidney causes) by 18% 1
   • Secondary cardiovascular outcomes by 14% 1

2. FIGARO-DKD trial: Showed:

   • 13% reduction in cardiovascular outcomes (cardiovascular death, MI, stroke, hospitalization for heart failure) 1
   • 36% reduction in end-stage kidney disease 1

3. FIDELITY pooled analysis (combining both trials, N=13,171) demonstrated:

   • 14% reduction in composite cardiovascular outcomes 1
   • 23% reduction in composite kidney outcomes 1
   • Benefits across the spectrum of CKD severity 1

Placement in Treatment Algorithm

Finerenone should be considered as part of a comprehensive approach for patients with type 2 diabetes and CKD:

1. First-line therapies:

   • SGLT2 inhibitors (initiate at eGFR ≥20 mL/min/1.73 m²)
   • Metformin (if eGFR ≥30 mL/min/1.73 m²)
   • RAS inhibitor at maximum tolerated dose (for hypertension)
   • Moderate/high-intensity statin

2. Additional risk-based therapy:

   • Finerenone for patients with albuminuria (UACR ≥30 mg/g) and normal potassium 1
   • GLP-1 receptor agonist if needed for glycemic control
   • Other antihypertensives if needed for BP control

Dosing Considerations

• Initial dose based on baseline eGFR:
  • 10 mg once daily for eGFR 25-60 mL/min/1.73 m²
  • 20 mg once daily for eGFR >60 mL/min/1.73 m²
• Dose increase from 10 mg to 20 mg may be considered after 1 month if:
  • Serum potassium ≤4.8 mmol/L
  • eGFR remains stable

Important Monitoring and Safety Considerations

• Hyperkalemia risk: More common with finerenone (10.8%) compared to placebo (5.3%) 1

  • Monitor serum potassium levels before initiation, at 4 weeks, and regularly thereafter
  • Baseline potassium should be <4.8 mEq/L before starting
  • Only 1.2% of patients discontinued due to hyperkalemia in clinical trials 1

• Contraindications:

  • Adrenal insufficiency
  • Severe hepatic impairment
  • Concomitant use of strong CYP3A4 inhibitors

Clinical Pearls

• Finerenone provides benefit regardless of baseline cardiovascular disease history
• Benefits observed across different levels of albuminuria and eGFR
• Can be used in combination with SGLT2 inhibitors for complementary mechanisms of action
• Unlike steroidal MRAs (spironolactone), finerenone does not cause gynecomastia
• Hyperkalemia risk is lower than with traditional steroidal MRAs but still requires monitoring

Finerenone represents an important addition to the therapeutic armamentarium for patients with type 2 diabetes and CKD, addressing the inflammatory and fibrotic pathways that contribute to disease progression.