What is the recommended use and dosing of Kerendia (finerenone) in patients with type 2 diabetes and chronic kidney disease?

Kerendia (Finerenone) Use and Dosing in Type 2 Diabetes with Chronic Kidney Disease

Finerenone (Kerendia) is recommended for patients with type 2 diabetes and CKD with albuminuria (ACR ≥30 mg/g) who are already on maximum tolerated doses of ACE inhibitors or ARBs to improve cardiovascular outcomes and reduce the risk of CKD progression. 1

Patient Selection Criteria

• Type 2 diabetes with chronic kidney disease
• Persistent albuminuria (ACR ≥30 mg/g)
• Already on maximum tolerated dose of RAS inhibitor (ACEi or ARB)
• eGFR ≥25 ml/min/1.73 m²
• Normal serum potassium (≤5.0 mmol/l)

Dosing Protocol

1. Starting dose based on eGFR:

   • eGFR >60 ml/min/1.73 m²: Start with 20 mg once daily
   • eGFR 25-60 ml/min/1.73 m²: Start with 10 mg once daily 1

2. Dose titration:

   • Monitor serum potassium 4 weeks after initiation or dose change
   • If potassium <4.8 mmol/l and tolerating current dose, uptitrate 10 mg dose to 20 mg daily
   • Continue treatment if potassium remains ≤5.5 mmol/l 1

3. Dose adjustment for hyperkalemia:

   • If potassium >5.5 mmol/l: Withhold finerenone
   • Can restart at 10 mg daily when potassium returns to ≤5.0 mmol/l 1

4. Continuation criteria:

   • Can continue with eGFR <25 ml/min/1.73 m² as long as potassium is acceptable and drug is otherwise tolerated 1

Clinical Benefits

Finerenone has demonstrated significant benefits in two major trials:

1. Cardiovascular outcomes:

   • 13% reduction in composite cardiovascular outcome (cardiovascular death, nonfatal MI, nonfatal stroke, or hospitalization for heart failure) 1, 2
   • Particularly effective at reducing heart failure hospitalizations 3

2. Kidney outcomes:

   • 23% reduction in kidney composite outcome (kidney failure, sustained ≥57% decrease in eGFR, or death from kidney causes) 1, 2
   • 20% reduction in progression to end-stage kidney disease 2

Monitoring Requirements

1. Serum potassium:

   • Baseline measurement before initiation
   • 4 weeks after initiation or dose change
   • Regular monitoring during treatment 1

2. Kidney function:

   • Monitor eGFR regularly
   • Note that early albuminuria reduction mediates 84% of the treatment effect against CKD progression 4

Important Precautions

1. Hyperkalemia risk:

   • Most common adverse effect (14% vs 6.9% with placebo)
   • Discontinuation due to hyperkalemia occurs in approximately 1.7% of patients 1
   • No deaths due to hyperkalemia reported in clinical trials 1

2. Medication interactions:

   • Avoid concomitant use of potassium supplements unless medically necessary
   • Use caution with other medications that may increase potassium

Place in Therapy Algorithm

1. First-line therapy:

   • SGLT2 inhibitor (initiate at eGFR ≥20 ml/min/1.73 m²; continue until dialysis or transplant)
   • Metformin (if eGFR ≥30 ml/min/1.73 m²)
   • RAS inhibitor at maximum tolerated dose (if hypertension present)

2. Add finerenone when:

   • Patient has persistent albuminuria despite maximum tolerated RAS inhibitor
   • Normal serum potassium
   • eGFR ≥25 ml/min/1.73 m²

3. Consider combination therapy:

   • Recent evidence shows that combination of finerenone with SGLT2 inhibitors (like empagliflozin) provides greater albuminuria reduction than either agent alone 5

Common Pitfalls to Avoid

1. Inadequate potassium monitoring:

   • Failure to check potassium before initiation and during follow-up
   • Not adjusting dose or temporarily withholding medication when potassium rises

2. Suboptimal patient selection:

   • Starting in patients with baseline hyperkalemia
   • Initiating at too high a dose in patients with reduced kidney function

3. Missing the opportunity for combination therapy:

   • Not considering the additive benefits of finerenone with SGLT2 inhibitors
   • The combination provides complementary mechanisms of action for cardiorenal protection 5

Finerenone represents an important addition to the therapeutic armamentarium for patients with type 2 diabetes and CKD, offering significant cardiovascular and kidney protection beyond what can be achieved with RAS inhibitors alone.