What's the latest about finerenone?

Latest Evidence on Finerenone: Cardiovascular and Renal Benefits

Finerenone is a novel non-steroidal mineralocorticoid receptor antagonist that significantly reduces both cardiovascular events and chronic kidney disease progression in patients with type 2 diabetes and CKD, with a 14% reduction in cardiovascular outcomes and 23% reduction in kidney outcomes across the spectrum of CKD severity. 1, 2

Cardiovascular Benefits

• Finerenone demonstrated a 13% reduction in the primary cardiovascular endpoint (cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure) compared to placebo in patients with type 2 diabetes and CKD 1, 2
• This benefit was primarily driven by a 29% reduction in heart failure hospitalizations (HR 0.71 [95% CI 0.56–0.90]) 1, 2
• The FIDELITY pooled analysis (combining FIGARO-DKD and FIDELIO-DKD trials with 13,171 participants) confirmed a 14% reduction in composite cardiovascular outcomes across the spectrum of CKD severity (HR 0.86 [95% CI 0.78–0.95]; P = 0.0018) 1, 2
• Recent evidence from the FINEARTS-HF trial shows significant benefits in patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) 3, 4

Renal Benefits

• Finerenone provides significant renal protection with a 23% reduction in composite kidney outcomes (sustained ≥57% decrease in eGFR or renal death) 1, 2
• Notable 36% reduction in end-stage kidney disease was observed (HR 0.64 [95% CI 0.41–0.995]) 1, 2
• Benefits are observed across a wide range of baseline kidney function (eGFR 25-90 mL/min/1.73 m²) 1, 2
• The FIDELIO-DKD trial demonstrated significant reduction in CKD progression with a hazard ratio of 0.82 [95% CI 0.73–0.93; P < 0.001] for the primary renal endpoint 1

Dosing and Patient Selection

• For patients with eGFR 25-60 mL/min/1.73 m², the recommended starting dose is 10 mg once daily 1, 2
• For patients with eGFR >60 mL/min/1.73 m², the recommended starting dose is 20 mg once daily 1, 2
• Dose uptitration from 10 to 20 mg daily is encouraged after 1 month if serum potassium remains ≤4.8 mmol/L and eGFR is stable 1
• Finerenone is particularly beneficial for patients with type 2 diabetes and CKD with elevated urinary albumin-to-creatinine ratio and eGFR 25-90 mL/min/1.73 m² 1, 5

Safety Profile and Hyperkalemia Management

• Finerenone is associated with increased risk of hyperkalemia (10.8% vs. 5.3% in placebo) 1, 4
• Despite this increased risk, treatment discontinuation due to hyperkalemia is relatively low (1.2% of patients on finerenone) 1, 4
• Recent data from FINEARTS-HF shows that with protocol-directed surveillance and dose adjustment, clinical benefits are maintained even in patients whose potassium levels increase to >5.5 mmol/L 4
• Finerenone has a more favorable hyperkalemia profile compared to steroidal MRAs like spironolactone due to its higher selectivity for the mineralocorticoid receptor 6, 7

Combination Therapy

• Finerenone can be used alongside SGLT2 inhibitors for complementary cardiorenal protection 5
• When combining with SGLT2 inhibitors, monitor renal function and potassium levels closely 5
• Avoid triple therapy with ACE inhibitors and ARBs together with these medications due to increased risk of adverse events 5
• Finerenone should be used with caution in patients already on ACE inhibitors or ARBs due to increased hyperkalemia risk 2, 5

Clinical Implications and Future Directions

• Finerenone represents a first-in-class, selective, nonsteroidal MRA approved for reducing the risk of sustained eGFR decline, end-stage renal disease, cardiovascular death, nonfatal MI, and hospitalization for heart failure in adults with CKD associated with type 2 diabetes 8
• Current guidelines suggest finerenone as an add-on therapy for patients with type 2 diabetes and CKD already treated with maximum tolerated doses of ACE inhibitors or ARBs 5
• Ongoing research is exploring finerenone's role in additional heart failure populations beyond the established benefits in HFpEF/HFmrEF 3, 7
• Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease and optimization of therapy 1