What is the recommended use and dosage of Finerenone (finerenone) for patients with chronic kidney disease (CKD) and heart failure?

Finerenone Use and Dosage for Chronic Kidney Disease and Heart Failure

Finerenone is strongly recommended for patients with type 2 diabetes and chronic kidney disease to reduce both kidney disease progression and cardiovascular events, particularly heart failure hospitalizations, with dosing based on baseline eGFR. 1

Indications and Benefits

• Finerenone is indicated for adults with chronic kidney disease associated with type 2 diabetes to reduce the risk of kidney disease progression and cardiovascular events 1, 2
• Provides significant cardiovascular protection with a 13% reduction in composite cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, and heart failure hospitalization) 1
• The cardiovascular benefit is primarily driven by a 29% reduction in heart failure hospitalizations (HR 0.71 [95% CI 0.56–0.90]) 1
• Offers substantial renal protection with a 23% reduction in composite kidney outcomes (sustained ≥57% decrease in eGFR or renal death) and a 36% reduction in end-stage kidney disease 1, 2

Dosing Recommendations

• 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
• Consider dose uptitration from 10 mg to 20 mg after 1 month if serum potassium remains ≤4.8 mmol/L and eGFR is stable 1
• Continue treatment across the spectrum of CKD severity (eGFR 25-90 mL/min/1.73 m²) 1

Patient Selection

• Most appropriate for patients with type 2 diabetes and CKD with:
  • Elevated urinary albumin-to-creatinine ratio (≥30 mg/g) 1
  • eGFR between 25-90 mL/min/1.73 m² 1, 2
  • Already on maximum tolerated dose of RAS inhibitors (ACE inhibitors or ARBs) 1
• Particularly beneficial for patients at risk of heart failure progression or hospitalization 1
• Can be used across the spectrum of CKD severity, regardless of baseline ASCVD history 1

Monitoring and Safety Considerations

• Monitor serum potassium levels regularly, as hyperkalemia is the most common adverse effect 1, 2
• Hyperkalemia occurs in approximately 10.8% of patients on finerenone (vs. 5.3% on placebo) 1
• Despite increased hyperkalemia risk, only about 1.2% of patients discontinue treatment due to this side effect 1
• Patients with heart failure with reduced ejection fraction were excluded from major trials, so evidence is stronger for heart failure with preserved ejection fraction 1
• Use caution when combining with other medications that may increase potassium levels 2

Combination with Other Therapies

• Finerenone can be used alongside SGLT2 inhibitors for complementary cardiorenal protection 1, 2
• In the FIDELIO-DKD trial, 4.5% of participants were also on SGLT2 inhibitors 1
• There have been no direct comparison studies between finerenone, SGLT2 inhibitors, and GLP-1 receptor agonists 1
• Healthcare professionals should use clinical judgment when deciding which medication to prescribe initially and in combination 1
• Use with caution in patients already on ACE inhibitors or ARBs due to increased hyperkalemia risk 2

When to Consider Nephrology Referral

• Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease 1, 2
• Referral may also be appropriate for difficult management issues such as resistant hypertension, significant albuminuria despite good blood pressure control, or electrolyte disturbances 1
• The threshold for referral may vary depending on the frequency with which a provider encounters patients with diabetes and kidney disease 1

Finerenone represents an important addition to the therapeutic arsenal for patients with CKD and type 2 diabetes, with proven benefits for both kidney and cardiovascular outcomes, particularly in reducing heart failure hospitalizations.