What is the recommended use and dosage of Finerenone (finerenone) for patients with chronic kidney disease (CKD) and heart failure?

Finerenone for Patients with Chronic Kidney Disease and Heart Failure

Finerenone is strongly recommended for patients with type 2 diabetes and chronic kidney disease with albuminuria who are already on maximum tolerated doses of ACE inhibitors or angiotensin receptor blockers to reduce the risk of CKD progression and cardiovascular events, particularly heart failure. 1

Patient Selection Criteria

Finerenone is specifically indicated for:

• Patients with type 2 diabetes and CKD
• Albuminuria ≥30 mg/g
• eGFR ≥25 ml/min/1.73 m²
• Serum potassium ≤4.8 mmol/L before initiation
• Patients already receiving maximum tolerated doses of RAS inhibitors (ACEIs or ARBs) 1

Dosing Recommendations

The dosing of finerenone follows a specific protocol:

• Starting dose:
  • 10 mg once daily for patients with eGFR 25-60 ml/min/1.73 m²
  • 20 mg once daily for patients with eGFR >60 ml/min/1.73 m² 1
• Dose titration:
  • After 4 weeks, if serum potassium remains ≤4.8 mmol/L and eGFR is stable, increase 10 mg dose to 20 mg once daily 1

Clinical Benefits

Finerenone provides significant benefits for both kidney and cardiovascular outcomes:

Kidney Protection

• Reduces risk of kidney disease progression by 23% (HR 0.77,95% CI: 0.67-0.88) 1
• Reduces risk of kidney failure requiring dialysis or transplantation (HR 0.80,95% CI: 0.64-0.99) 1

Cardiovascular Protection

• Reduces composite cardiovascular events by 13-14% (HR 0.86,95% CI: 0.78-0.95) 1
• Specifically reduces hospitalization for heart failure (HR 0.71,95% CI: 0.56-0.90) 2, 3
• Reduces new-onset heart failure by 32% (HR 0.68,95% CI: 0.50-0.93) 3
• Reduces new-onset atrial fibrillation by 29% (HR 0.71,95% CI: 0.53-0.94) 4

Monitoring and Safety

Hyperkalemia Management

Hyperkalemia is the primary adverse effect requiring careful monitoring:

• Check serum potassium and renal function at 1 month after initiation
• Continue monitoring every 4 months thereafter 1

Hyperkalemia Protocol

If serum potassium >5.5 mmol/L:

1. Hold finerenone
2. Adjust diet or concomitant medications
3. Recheck potassium levels
4. Consider reinitiation at 10 mg daily when K+ ≤5.0 mmol/L 1

Discontinuation Criteria

• Discontinue if serum potassium >5.5 mmol/L despite medical management
• Discontinue if severe hyperkalemia requiring emergency intervention occurs 1

Combination Therapy

Finerenone can be effectively combined with:

• SGLT2 inhibitors (first-line treatment for type 2 diabetes and CKD)
• GLP-1 receptor agonists with proven cardiovascular benefits
• Metformin (if eGFR remains >30 mL/min/1.73 m²) 1

Important Clinical Considerations

1. Hyperkalemia risk: The incidence of hyperkalemia is higher with finerenone (10.8%) compared to placebo (5.3%) in clinical trials 1, 5

2. Patient selection: Avoid finerenone in patients with serum potassium >4.8 mmol/L or eGFR <25 mL/min/1.73 m² 1

3. Unique benefits: Unlike steroidal MRAs (spironolactone, eplerenone), finerenone has no effect on HbA1c, body weight, and does not cause sexual side effects including gynecomastia 6

4. Heart failure prevention: Finerenone is particularly effective at reducing the risk of progression from stage A heart failure to symptomatic incident heart failure in patients with type 2 diabetes and CKD 2