Can Kerendia (finerenone) be used in a patient with a history of pancreatitis or diabetic ketoacidosis?

Kerendia (Finerenone) Use in Patients with History of Pancreatitis or Diabetic Ketoacidosis

Kerendia (finerenone) can be safely used in patients with a history of pancreatitis or diabetic ketoacidosis (DKA), as there are no specific contraindications for these conditions in current clinical guidelines.

Mechanism and Clinical Context

Finerenone is a non-steroidal mineralocorticoid receptor antagonist (MRA) indicated for patients with type 2 diabetes and chronic kidney disease with albuminuria. Unlike some other diabetes medications, it works through a different mechanism:

• Finerenone acts by blocking mineralocorticoid receptors, reducing inflammation and fibrosis in the kidneys
• It does not affect glucose metabolism directly like insulin, sulfonylureas, or SGLT2 inhibitors
• It has demonstrated cardiovascular and renal benefits in clinical trials 1

Evidence for Safety in Pancreatitis

Unlike incretin-based therapies (GLP-1 receptor agonists and DPP-4 inhibitors) which have documented associations with pancreatitis risk 2, there is no evidence suggesting finerenone increases pancreatitis risk:

• Current guidelines for diabetes management in patients with history of pancreatitis specifically caution against GLP-1 receptor agonists and DPP-4 inhibitors 2
• Finerenone is not mentioned among medications associated with gastrointestinal adverse events including pancreatitis 2
• The FIDELIO-DKD and FIGARO-DKD trials did not report pancreatitis as a significant adverse event with finerenone 3, 1

Evidence for Safety in Diabetic Ketoacidosis

Unlike SGLT2 inhibitors which carry warnings about increased risk of DKA 3, finerenone does not have this risk profile:

• SGLT2 inhibitors increase susceptibility to DKA through multiple mechanisms including increased ketone production and decreased renal clearance of ketones 3
• Finerenone works through the mineralocorticoid receptor pathway and does not affect ketone metabolism 1
• Clinical trials of finerenone did not report increased risk of DKA 3, 1

Monitoring Considerations

While finerenone can be used in patients with history of pancreatitis or DKA, appropriate monitoring is still important:

• Monitor serum potassium levels as finerenone can cause hyperkalemia, though less pronounced than with spironolactone 1
• Initial potassium should be ≤4.8 mEq/L before starting treatment
• Recheck potassium 4 weeks after initiation and with dose adjustments
• For patients with history of DKA, continue standard monitoring for recurrent DKA risk factors

Clinical Decision Algorithm

1. Assess eligibility for finerenone:

   • Confirmed type 2 diabetes with CKD and albuminuria
   • eGFR ≥25 mL/min/1.73m²
   • Serum potassium ≤4.8 mEq/L

2. Review history of pancreatitis or DKA:

   • No dose adjustment needed specifically for history of these conditions
   • Identify and address ongoing risk factors for recurrence

3. Consider medication interactions:

   • Ensure patient is on appropriate RAS inhibitor therapy
   • Consider if patient is on other medications that may increase hyperkalemia risk

4. Initiate finerenone:

   • Start with 10 mg once daily if eGFR 25-60 mL/min/1.73m²
   • Start with 20 mg once daily if eGFR ≥60 mL/min/1.73m²

5. Monitor:

   • Check serum potassium at 4 weeks
   • Adjust dose based on potassium levels and tolerability

Conclusion

Finerenone represents a safe option for patients with history of pancreatitis or DKA, particularly when compared to alternatives like GLP-1 receptor agonists (pancreatitis risk) or SGLT2 inhibitors (DKA risk). The main safety concern with finerenone is hyperkalemia, which requires appropriate monitoring but is unrelated to pancreatitis or DKA risk.