What are the guidelines for prescribing Finerenone?

From the Guidelines

Finerenone should be prescribed at an initial dose of 10 mg once daily for patients with an estimated glomerular filtration rate (eGFR) 25-59 mL/min/1.73m² and serum potassium ≤4.8 mmol/L, and 20 mg daily if eGFR ≥60 mL/min/1.73m², with regular monitoring of serum potassium levels, as recommended by the KDIGO 2024 clinical practice guideline 1.

Key Considerations for Prescribing Finerenone

• The initial dose of finerenone depends on the patient's eGFR, with 10 mg daily for eGFR 25-59 mL/min/1.73m² and 20 mg daily for eGFR ≥60 mL/min/1.73m².
• Serum potassium levels should be monitored regularly, with measurements taken at 1 month after initiation and then every 4 months.
• The dose can be increased to 20 mg daily if the patient is currently taking 10 mg daily and their serum potassium level remains ≤4.8 mmol/L.
• Finerenone should be held if the patient's serum potassium level exceeds 5.5 mmol/L, and consideration should be given to adjusting the patient's diet or concomitant medications to mitigate hyperkalemia.

Indications and Contraindications for Finerenone

• Finerenone is primarily indicated for patients with chronic kidney disease associated with type 2 diabetes to reduce the risk of kidney function decline, kidney failure, cardiovascular death, non-fatal myocardial infarction, and heart failure hospitalization.
• Finerenone should be used cautiously with CYP3A4 inhibitors and is contraindicated with strong CYP3A4 inhibitors, as well as in patients with adrenal insufficiency or severe hepatic impairment.

Evidence Supporting the Use of Finerenone

• The FIGARO-DKD study demonstrated a 13% reduction in the primary composite outcome of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure in patients treated with finerenone compared to placebo 1.
• The KDIGO 2024 clinical practice guideline recommends the use of finerenone in patients with chronic kidney disease and type 2 diabetes to reduce the risk of kidney function decline and cardiovascular events 1.

From the Research

Guidelines for Prescribing Finerenone

The guidelines for prescribing finerenone are based on several studies that have evaluated its efficacy and safety in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus. The key points to consider when prescribing finerenone are:

• Finerenone is a nonsteroidal selective mineralocorticoid receptor antagonist (MRA) that has been shown to delay the progression of CKD and reduce cardiovascular events in patients with CKD and type 2 diabetes mellitus 2, 3, 4.
• The dose of finerenone should be titrated based on serum potassium levels and estimated glomerular filtration rate (eGFR) 2.
• The potassium limit for inclusion and uptitration from finerenone 10 to 20 mg is ≤ 4.8 mmol/L 2.
• Patients who experience hyperkalemia (serum potassium > 5.5 mmol/L) should have their treatment withheld until serum potassium is ≤ 5.0 mmol/L, and then the treatment should be restarted at the 10 mg daily dose 3.
• Routine potassium monitoring and hyperkalemia management strategies are essential to minimize the impact of hyperkalemia and ensure the safe use of finerenone 4.

Key Considerations

Some key considerations when prescribing finerenone include:

• The risk of hyperkalemia is higher in patients with advanced CKD, those taking other medications that increase potassium levels, and those with a history of hyperkalemia 3, 5.
• The use of finerenone in patients with resistant hypertension and moderate-to-advanced CKD has been shown to be effective in reducing systolic blood pressure and increasing serum potassium concentration 5.
• Finerenone has been compared to spironolactone, another MRA, and has been shown to have a lower risk of hyperkalemia and treatment discontinuation due to hyperkalemia 5.

Practical Recommendations

Some practical recommendations for prescribing finerenone include:

• Monitoring serum potassium levels regularly, especially in patients with advanced CKD or those taking other medications that increase potassium levels 4.
• Adjusting the dose of finerenone based on serum potassium levels and eGFR 2.
• Withholding treatment and restarting at a lower dose if hyperkalemia occurs 3.
• Considering the use of finerenone in patients with type 2 diabetes and CKD, especially those with albuminuria and impaired kidney function 6.