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

Finerenone Use and Dosage for CKD and Heart Failure

Finerenone is strongly recommended at a starting dose of 10 mg once daily for patients with type 2 diabetes and chronic kidney disease with albuminuria (eGFR 25-60 ml/min/1.73 m²) 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

• Appropriate for patients with:

  • eGFR ≥25 ml/min/1.73 m²
  • Persistent albuminuria (ACR ≥30 mg/g)
  • Serum potassium <4.8 mmol/L 1
  • Type 2 diabetes with CKD 2

• Contraindicated in:

  • Patients with serum potassium >4.8 mmol/L
  • eGFR <25 mL/min/1.73 m² 1

Dosing Algorithm

1. Initial dosing:

   • 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

2. 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

3. Monitoring requirements:

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

Clinical Benefits

Finerenone provides significant benefits for patients with CKD and type 2 diabetes:

• Kidney outcomes: Reduces risk of kidney disease progression by 23% (HR 0.77,95% CI: 0.67-0.88) 1

• Cardiovascular outcomes:

  • 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) 1, 3
  • Reduces new-onset heart failure by 32% (HR 0.68,95% CI: 0.50-0.93) 1, 3
  • Reduces risk of sudden cardiac death vs. placebo (HR 0.75; 95% CI, 0.57-0.996) 4

• Additional benefits:

  • Reduces new-onset atrial fibrillation (HR: 0.71; 95% CI: 0.53-0.94) 5
  • Reduces risk of kidney failure requiring dialysis or transplantation (HR 0.80,95% CI: 0.64-0.99) 1

Management of Adverse Effects

The primary adverse effect is hyperkalemia:

• Incidence: 10.8% with finerenone vs. 5.3% with placebo 1
• Management algorithm for hyperkalemia:
  • If 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
  • Discontinue permanently if severe hyperkalemia requiring emergency intervention occurs 1

Combination Therapy

Finerenone can be effectively combined with:

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

Clinical Pearls and Pitfalls

• Key advantage: Unlike steroidal MRAs (spironolactone, eplerenone), finerenone has no effect on HbA1c, body weight, and does not cause sexual side effects including gynecomastia 6

• Common pitfall: Failure to monitor potassium levels can lead to dangerous hyperkalemia. Always check potassium at 1 month and every 4 months thereafter 1

• Important consideration: Finerenone provides benefits across the spectrum of CKD in patients with type 2 diabetes, regardless of baseline heart failure status 3

• Caution: Safety data in real-world settings is still emerging, so vigilant monitoring is essential, particularly for hyperkalemia 6