Potassium Threshold for Patients Taking Kerendia (Finerenone)
Patients taking Kerendia (finerenone) should have a serum potassium level ≤5.0 mmol/L before initiation, with regular monitoring to maintain levels below 5.5 mmol/L during treatment.
Initial Potassium Requirements
- Before starting finerenone, serum potassium must be ≤5.0 mmol/L 1
- Patients should have consistently normal serum potassium concentration prior to initiation of this nonsteroidal mineralocorticoid receptor antagonist (MRA) 1
- Regular potassium monitoring is essential to prevent and manage hyperkalemia during treatment 1
Monitoring Protocol During Treatment
- Serum potassium should be monitored prior to drug initiation and periodically during treatment 1
- After starting finerenone, potassium levels should be checked within the first 5-7 days 1
- Continue monitoring every 5-7 days until potassium values stabilize 1
- Once stable, check at 3 months and subsequently at 6-month intervals 2
- More frequent monitoring is needed in patients with risk factors such as renal impairment, heart failure, and concurrent use of medications affecting potassium 2
Management Based on Potassium Levels
- If serum potassium rises to >5.5 mmol/L, current guidelines recommend halving the dose of finerenone and closely monitoring blood chemistry 1, 2
- If serum potassium exceeds 6.0 mmol/L, cessation of finerenone therapy is advised 1, 2
- Treatment can be restarted at a lower dose once potassium levels return to ≤5.0 mmol/L 3
Risk Factors for Hyperkalemia with Finerenone
- Independent risk factors for hyperkalemia (>5.5 mmol/L) while on finerenone include: higher baseline serum potassium, lower eGFR, increased urine albumin-creatinine ratio, younger age, female sex, and β-blocker use 3
- Diuretic or sodium-glucose cotransporter-2 inhibitor use may reduce the risk of hyperkalemia 3
- Finerenone has a lower risk of hyperkalemia compared to traditional steroidal MRAs like spironolactone, but still requires careful monitoring 4, 5
Clinical Considerations
- Finerenone is indicated for adults with type 2 diabetes and chronic kidney disease with albuminuria 6, 4
- The drug has demonstrated significant reductions in cardiovascular and renal outcomes in patients with CKD and type 2 diabetes 6, 7
- Despite the increased risk of hyperkalemia with finerenone compared to placebo, treatment discontinuation due to hyperkalemia was relatively low in clinical trials (1.7% vs 0.6%) 7
- No deaths attributable to hyperkalemia were reported in the clinical trials 5
Common Pitfalls to Avoid
- Failing to check baseline potassium levels before initiating finerenone 1
- Not monitoring potassium levels regularly after starting therapy 1
- Continuing finerenone at the same dose when potassium levels exceed 5.5 mmol/L 1, 2
- Not considering potential drug interactions with other medications that may affect potassium levels 4
- Ignoring the need for more frequent monitoring in high-risk patients 2