What is the recommended dosing for finerenone (Mineralocorticoid Receptor Antagonist) in patients with Chronic Kidney Disease (CKD)?

Finerenone Dosing in Chronic Kidney Disease

For patients with CKD, finerenone should be initiated at 10 mg once daily if eGFR is 25-59 ml/min/1.73 m² and 20 mg once daily if eGFR is ≥60 ml/min/1.73 m², with dose titration possible after 1 month if serum potassium remains ≤4.8 mmol/L and eGFR is stable. 1, 2

Patient Selection and Prerequisites

• eGFR threshold: Finerenone should only be initiated in patients with eGFR ≥25 ml/min/1.73 m² 1, 2
• Potassium requirement: Baseline serum potassium must be ≤4.8 mmol/L 1, 2
• Primary indication: Most appropriate for patients with type 2 diabetes who have albuminuria (≥30 mg/g) despite maximum tolerated dose of RAS inhibitor 1
• Contraindications: Adrenal insufficiency 2

Dosing Algorithm

1. Initial dose determination:

   • eGFR 25-59 ml/min/1.73 m²: Start with 10 mg once daily
   • eGFR ≥60 ml/min/1.73 m²: Start with 20 mg once daily

2. Dose titration:

   • After 1 month, check serum potassium and eGFR
   • If K+ ≤4.8 mmol/L and eGFR is stable, increase 10 mg dose to 20 mg once daily
   • Continue current dose if K+ is 4.9-5.5 mmol/L

3. Dose adjustment for hyperkalemia:

   • If K+ >5.5 mmol/L: Hold finerenone
   • Consider dietary modifications and adjustment of concomitant medications
   • May reinitiate at 10 mg daily when K+ ≤5.0 mmol/L

Monitoring Protocol

• Initial monitoring: Check serum potassium at 1 month after initiation
• Ongoing monitoring: Monitor serum potassium every 4 months thereafter 1
• Additional monitoring: Assess renal function regularly, particularly in patients with more advanced CKD

Clinical Considerations

• Efficacy: Finerenone reduces kidney disease progression by 23% and cardiovascular events by 14% in patients with type 2 diabetes and CKD 2
• Hyperkalemia risk: In clinical trials, hyperkalemia occurred in 10.8% of finerenone patients vs. 5.3% of placebo patients, with discontinuation due to hyperkalemia in 2.3% vs. 0.9% 1, 2
• Combination therapy: Finerenone can be safely combined with SGLT2 inhibitors for additive cardiorenal protection 1, 2, 3

Special Situations

• Patients on SGLT2 inhibitors: No dose adjustment needed; combination therapy may provide additive benefits 1, 2, 3
• Non-diabetic CKD: Currently being investigated in the FIND-CKD trial; no specific recommendations available yet 4
• Temporary discontinuation: Consider holding finerenone during periods of acute illness that may increase risk of hyperkalemia

Common Pitfalls to Avoid

1. Initiating in patients with K+ >4.8 mmol/L: This increases risk of dangerous hyperkalemia
2. Starting with high dose in patients with reduced eGFR: Always use 10 mg in patients with eGFR <60 ml/min/1.73 m²
3. Inadequate potassium monitoring: Failure to check K+ at 1 month and every 4 months thereafter
4. Missing dose titration opportunity: Patients on 10 mg with stable K+ ≤4.8 mmol/L should be uptitrated to 20 mg for optimal benefit
5. Permanent discontinuation after transient hyperkalemia: Consider restarting at lower dose once K+ normalizes to ≤5.0 mmol/L

By following this structured approach to finerenone dosing in CKD patients, clinicians can maximize cardiorenal benefits while minimizing the risk of hyperkalemia.