Why is Kerendia (finerenone) preferred over spironolactone in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM)?

Kerendia (Finerenone) vs. Spironolactone in Chronic Kidney Disease with Type 2 Diabetes

Kerendia (finerenone) is preferred over spironolactone in patients with chronic kidney disease and type 2 diabetes due to its proven cardiovascular and kidney protective benefits with significantly lower risk of hyperkalemia and absence of endocrine side effects. 1

Key Advantages of Finerenone Over Spironolactone

1. Proven Clinical Outcomes

• Kidney Protection: Finerenone reduces the risk of kidney disease progression by 23% (HR 0.77,95% CI: 0.67-0.88) in patients with CKD and T2DM 2
• Cardiovascular Protection: Finerenone reduces cardiovascular events by 13-14% (HR 0.86,95% CI: 0.78-0.95) 1
• End-Stage Kidney Disease: Finerenone reduces the risk of kidney failure requiring dialysis or transplantation (HR 0.80,95% CI: 0.64-0.99) 2

2. Safety Profile Advantages

• Lower Hyperkalemia Risk: While hyperkalemia occurs with finerenone (14% vs 6.9% with placebo), it leads to significantly fewer discontinuations (1.7% vs 0.6%) compared to spironolactone 2
• No Endocrine Side Effects: Unlike spironolactone, finerenone does not cause gynecomastia or other sex hormone-related side effects 3
• No Deaths from Hyperkalemia: In clinical trials, no deaths due to hyperkalemia were reported with finerenone 2

3. Evidence-Based Support

• Spironolactone has shown poor tolerability in CKD patients, with two-thirds of patients discontinuing within 6 months due to safety concerns 4
• Recent research shows spironolactone provides no cardiovascular benefit in stage 3b CKD patients (HR 1.05,95% CI: 0.81-1.37) 4
• Finerenone has been specifically studied and approved for diabetic kidney disease, while spironolactone has not 5

Patient Selection for Finerenone

Finerenone is indicated for patients with:

• Type 2 diabetes with CKD
• eGFR ≥25 mL/min/1.73 m²
• Albuminuria (ACR ≥30 mg/g)
• Serum potassium ≤4.8 mmol/L
• Already on maximum tolerated dose of RAS inhibitor (ACEI or ARB) 1

Dosing and Administration

1. Initial Dosing:

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

2. Dose Titration:

   • After 4 weeks, if serum K+ remains ≤4.8 mmol/L and eGFR is stable, increase 10 mg dose to 20 mg once daily 2

Monitoring Requirements

• Check serum potassium and renal function at 1 month after initiation
• Continue monitoring every 4 months thereafter 1
• For K+ >5.5 mmol/L: Hold finerenone, adjust diet or concomitant medications, recheck K+
• Consider reinitiation at 10 mg daily when K+ ≤5.0 mmol/L 1

Combination Therapy

Finerenone can be effectively combined with:

• SGLT2 inhibitors (first-line therapy for T2DM with CKD)
• GLP-1 receptor agonists with proven cardiovascular benefits
• Metformin (if eGFR remains >30 mL/min/1.73 m²) 1

Clinical Pearls and Pitfalls

• Key Pitfall: Failing to monitor potassium levels regularly can lead to undetected hyperkalemia
• Important Consideration: Unlike spironolactone, finerenone is a non-steroidal MRA with selective binding to the mineralocorticoid receptor, explaining its improved safety profile 6
• Practice Tip: Consider temporarily withholding potassium supplements and potassium-sparing diuretics when initiating finerenone
• Caution: Avoid finerenone in patients with baseline serum potassium >4.8 mmol/L or eGFR <25 mL/min/1.73 m² 1

In conclusion, the evidence strongly supports using finerenone over spironolactone in patients with CKD and T2DM due to its proven cardiorenal benefits and superior safety profile, particularly regarding hyperkalemia risk and absence of endocrine side effects.