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

Recommended Use and Dosage of Kerendia (Finerenone) for CKD and Type 2 Diabetes

Finerenone (Kerendia) 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. 1

Patient Selection Criteria

Finerenone should be prescribed for patients who meet the following criteria:

• Type 2 diabetes with chronic kidney disease
• eGFR ≥25 ml/min/1.73 m²
• Persistent albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g)
• Serum potassium <4.8 mmol/L
• Already on maximum tolerated doses of ACE inhibitors or ARBs 1

Finerenone is contraindicated in patients with:

• Serum potassium >4.8 mmol/L
• eGFR <25 mL/min/1.73 m² 1

Dosing Protocol

The dosing of finerenone follows a stepwise approach based on kidney function:

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

Clinical Benefits

Finerenone has demonstrated significant benefits in large clinical trials:

• Reduces risk of kidney disease progression by 23% (HR 0.77,95% CI: 0.67-0.88) 1, 2
• Reduces risk of composite cardiovascular events by 13-14% (HR 0.86,95% CI: 0.78-0.95) 1, 2
• Specifically reduces:
  • Hospitalization for heart failure (HR 0.71,95% CI: 0.56-0.90) 1, 3
  • New-onset heart failure by 32% (HR 0.68,95% CI: 0.50-0.93) 1, 3
  • Risk of kidney failure requiring dialysis or transplantation (HR 0.80,95% CI: 0.64-0.99) 1

Monitoring Requirements

Careful monitoring is essential due to the risk of hyperkalemia:

• Check serum potassium and renal function at 1 month after initiation
• Continue monitoring every 4 months thereafter 1
• Hyperkalemia incidence: 10.8% with finerenone vs. 5.3% with placebo in clinical trials 1

Management of Hyperkalemia

If hyperkalemia occurs, follow this protocol:

• 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

• Discontinue finerenone permanently if:

  • Serum potassium >5.5 mmol/L despite medical management
  • Severe hyperkalemia requiring emergency intervention occurs 1

Combination Therapy

Finerenone can be effectively combined with:

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

The American Diabetes Association recommends starting with an SGLT2 inhibitor (empagliflozin) in patients with CKD and type 2 diabetes with eGFR ≥20 mL/min/1.73 m², and then adding finerenone for additional cardiorenal protection 1.

Clinical Pearls

• The blood pressure-lowering effect of finerenone accounts for only a small proportion (12.6-13.8%) of its cardiorenal benefits 4
• Finerenone has a more favorable hyperkalemia profile compared to steroidal mineralocorticoid receptor antagonists like spironolactone, but still requires careful monitoring 2, 5
• Benefits are seen across all baseline systolic blood pressure quartiles 4
• In Belgium, finerenone is reimbursed with conditions in combination with a renin-angiotensin blocker 2