Which patients should be started on Finerenone?

Finerenone Initiation in Patients with Type 2 Diabetes and Chronic Kidney Disease

Finerenone should be initiated in patients with type 2 diabetes who have chronic kidney disease with eGFR ≥25 mL/min/1.73 m² and albuminuria (UACR ≥30 mg/g) despite maximum tolerated dose of RAS inhibitors, with normal serum potassium levels (≤4.8 mmol/L). 1

Patient Selection Criteria

• Patients with type 2 diabetes and CKD with eGFR 25-90 mL/min/1.73 m² 1
• Patients with albuminuria (UACR ≥30 mg/g) despite being on maximum tolerated dose of RAS inhibitors 1
• Patients with normal serum potassium concentration (≤4.8 mmol/L) 1
• Particularly beneficial for patients at high risk of CKD progression and cardiovascular events 1, 2

Specific Patient Populations by CKD Stage and Albuminuria

• Moderately elevated albuminuria (UACR 30-300 mg/g):

  • With eGFR 25-60 mL/min/1.73 m² 1
  • With eGFR 60-90 mL/min/1.73 m² 1

• Severely elevated albuminuria (UACR 300-5000 mg/g):

  • With eGFR 25-75 mL/min/1.73 m² 1

Dosing Algorithm

1. Initial dosing based on kidney function:

   • eGFR 25-60 mL/min/1.73 m²: Start with 10 mg once daily 1
   • eGFR ≥60 mL/min/1.73 m²: Start with 20 mg once daily 1

2. Dose titration:

   • After 1 month, consider increasing dose from 10 mg to 20 mg once daily if: 1
     • Serum potassium remains ≤4.8 mmol/L
     • eGFR remains stable

3. Potassium monitoring:

   • Check serum potassium 1 month after initiation 1
   • Then monitor every 4 months 1
   • If potassium increases to >5.5 mmol/L, withhold finerenone 1
   • Can restart at 10 mg daily when potassium returns to ≤5.0 mmol/L 1

Clinical Benefits

• Kidney outcomes: 18% reduction in primary kidney composite endpoint (kidney failure, sustained ≥40% decrease in eGFR, or renal death) 1
• Cardiovascular outcomes: 14% reduction in composite cardiovascular outcomes across the spectrum of CKD severity 1, 2
• Heart failure reduction: 29% reduction in heart failure hospitalizations 2, 3
• End-stage kidney disease: 36% reduction in end-stage kidney disease 1, 2

Combination with Other Therapies

• Can be used alongside SGLT2 inhibitors for complementary cardiorenal protection 2, 4
• Recent evidence shows that combination therapy with SGLT2 inhibitors (empagliflozin) provides greater albuminuria reduction than either agent alone 4
• Only 4.5% of patients in the FIDELIO-DKD trial were on SGLT2 inhibitors, but the benefits of finerenone were observed regardless 1

Safety Considerations and Monitoring

• Hyperkalemia risk:

  • Higher incidence of hyperkalemia with finerenone (10.8%) vs. placebo (5.3%) 1
  • Discontinuation due to hyperkalemia: 1.2% with finerenone vs. 0.4% with placebo 1
  • No deaths related to hyperkalemia were reported in clinical trials 1

• Blood pressure effects:

  • Finerenone reduces 24-hour ambulatory blood pressure despite its short half-life 5
  • Consider this effect when managing patients with low baseline blood pressure 5

When to Refer to Nephrology

• Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease 1
• Referral is appropriate for difficult management issues including electrolyte disturbances or resistant hypertension 1

Common Pitfalls to Avoid

• Failure to monitor potassium: Regular monitoring is essential to prevent hyperkalemia complications 1
• Inappropriate patient selection: Avoid use in patients with baseline hyperkalemia (>4.8 mmol/L) 1
• Missing dose titration opportunity: Many patients can safely increase from 10 mg to 20 mg after 1 month if potassium and eGFR remain stable 1
• Not considering combination therapy: Finerenone can provide complementary benefits when used with SGLT2 inhibitors 2, 4