Indications to Start Kerendia (Finerenone)
Kerendia (finerenone) should be initiated in patients with type 2 diabetes and chronic kidney disease who have persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated dose of RAS inhibitors, with an eGFR ≥25 mL/min/1.73 m² and normal serum potassium levels. 1
Patient Selection Criteria
- Finerenone is indicated for patients with type 2 diabetes and CKD with albuminuria (UACR ≥30 mg/g) who are already on maximum tolerated dose of ACE inhibitor or ARB therapy 1
- Eligible patients should have an eGFR between 25-90 mL/min/1.73 m² 1
- Serum potassium must be ≤4.8 mmol/L before initiation 1
- Particularly beneficial for patients at high risk of CKD progression and cardiovascular events despite standard therapy 1, 2
Dosing Algorithm
- For patients with eGFR 25-60 mL/min/1.73 m²: Start with 10 mg once daily 1, 2
- For patients with eGFR >60 mL/min/1.73 m²: Start with 20 mg once daily 1, 2
- Dose increase from 10 mg to 20 mg can be considered after 1 month if serum potassium remains ≤4.8 mmol/L and eGFR is stable 1
Clinical Benefits
- Reduces risk of CKD progression with a 23% reduction in composite kidney outcomes (sustained ≥57% decrease in eGFR or renal death) 1, 2
- Decreases cardiovascular events with a 14% reduction in composite cardiovascular outcomes (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for heart failure) 1
- Provides a 36% reduction in end-stage kidney disease compared to placebo (HR 0.64 [95% CI 0.41–0.995]) 1, 2
- Reduces heart failure hospitalizations by 29% (HR 0.71 [95% CI 0.56–0.90]) 1, 3
- Reduces new-onset heart failure by 32% in patients without prior heart failure history 3
Monitoring Requirements
- Check serum potassium before initiation and periodically during treatment 1
- Monitor serum creatinine and eGFR to assess kidney function 1
- Watch for hyperkalemia, which occurred in 10.8% of patients on finerenone versus 5.3% on placebo in clinical trials 1
- Treatment discontinuation due to hyperkalemia is relatively low (1.2% in the FIGARO-DKD trial) 1, 2
Combination Therapy Considerations
- Finerenone can be used alongside SGLT2 inhibitors for complementary cardiorenal protection 2, 4
- Recent evidence shows that combination therapy with finerenone and empagliflozin provides a 29-32% greater reduction in albuminuria compared to either agent alone 4
- Consider finerenone after SGLT2 inhibitors in the treatment algorithm, as SGLT2 inhibitors have shown larger effects on reducing both kidney and cardiovascular outcomes 1
- Only 4.5% of patients in the FIDELIO-DKD trial were on SGLT2 inhibitors, so most evidence for finerenone is as monotherapy or with RAS inhibitors 1
Contraindications and Cautions
- Avoid in patients with serum potassium >4.8 mmol/L 1
- Use with caution in patients already on ACE inhibitors or ARBs due to increased hyperkalemia risk 2
- Patients with heart failure with reduced ejection fraction were excluded from the FIGARO-DKD trial 1, 2
- Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease 1, 2
Common Pitfalls to Avoid
- Failure to monitor serum potassium regularly, which is essential to prevent and manage hyperkalemia 1
- Not checking baseline potassium levels before initiation 1
- Starting with too high a dose in patients with reduced kidney function 1
- Not considering finerenone in patients who remain at high risk despite SGLT2 inhibitor therapy 1, 4
- Overlooking the potential benefits in patients with mild albuminuria (30-300 mg/g), as benefits extend across the spectrum of albuminuria 1