Is finerenone (mineralocorticoid receptor antagonist) indicated for patients with heart failure and chronic kidney disease?

Is Finerenone Indicated for Heart Failure and Chronic Kidney Disease?

Yes, finerenone is indicated for patients with type 2 diabetes and chronic kidney disease (CKD) who have persistent albuminuria (ACR ≥30 mg/g) despite maximum tolerated renin-angiotensin system (RAS) inhibitor therapy, with eGFR ≥25 mL/min/1.73 m² and normal serum potassium (<4.8 mmol/L). 1

Primary Indication and Patient Selection

Finerenone is specifically recommended for adults with type 2 diabetes and CKD to reduce both cardiovascular and renal outcomes. 2 The drug provides dual benefits:

• Cardiovascular protection: 13% reduction in the composite of cardiovascular death, nonfatal MI, nonfatal stroke, or hospitalization for heart failure 2, 1, 3
• Renal protection: 23% reduction in kidney failure, sustained ≥57% decrease in eGFR, or renal death 1, 3

The most compelling benefit is a 29% reduction in heart failure hospitalizations (HR 0.71,95% CI 0.56-0.90), which drives much of the cardiovascular benefit. 3

Specific Patient Criteria

Eligible patients must meet ALL of the following:

• Type 2 diabetes with CKD 1
• Persistent albuminuria (ACR ≥30 mg/g) despite maximum tolerated RAS inhibitor therapy 1
• eGFR ≥25 mL/min/1.73 m² 1
• Serum potassium <4.8 mmol/L at baseline 1
• Already on optimized RAS blockade (ACE inhibitor or ARB) 2, 4

Important exclusion: Patients with symptomatic heart failure with reduced ejection fraction (HFrEF) were excluded from the pivotal FIGARO-DKD trial, so evidence is stronger for heart failure with preserved ejection fraction (HFpEF). 3

Dosing Algorithm

For eGFR 25-60 mL/min/1.73 m²:

• Start 10 mg once daily 1, 3
• After 4 weeks, if serum potassium remains <4.8 mmol/L, uptitrate to 20 mg once daily 1

For eGFR >60 mL/min/1.73 m²:

• Start 20 mg once daily 1, 3

Potassium Monitoring Protocol

• Check serum potassium before initiation (must be <4.8 mmol/L) 1
• Recheck at 4 weeks after initiation or dose increase 1
• If potassium >5.5 mmol/L: Withhold finerenone and restart at 10 mg daily when potassium ≤5.0 mmol/L 1

While hyperkalemia occurs more frequently with finerenone (14% vs 6.9% with placebo), severe hyperkalemia requiring permanent discontinuation is relatively low (1.7-2.3% vs 0.6-1.0% with placebo). 1, 3, 4

Therapeutic Positioning in Treatment Algorithm

The American Diabetes Association and National Kidney Foundation recommend the following hierarchy for patients with type 2 diabetes and CKD: 2, 1

1. First-line: RAS inhibitor (ACE inhibitor or ARB)
2. Second-line: SGLT2 inhibitor (prioritized over finerenone due to larger effects on kidney and cardiovascular outcomes) 1
3. Third-line: Add finerenone if:
   • Patient does not tolerate SGLT2 inhibitor, OR
   • Albuminuria persists despite SGLT2 inhibitor therapy 1

Finerenone can be used alongside SGLT2 inhibitors for complementary cardiorenal protection, as the mechanisms are additive. 5, 3 The pooled FIDELITY analysis of 13,026 patients demonstrated consistent benefits across the spectrum of kidney function and albuminuria severity. 2, 6

Clinical Evidence Supporting Use

The recommendation is based on two landmark trials:

• FIDELIO-DKD: Demonstrated improved CKD outcomes in patients with stage 3-4 CKD and severe albuminuria 2
• FIGARO-DKD: Showed 13% reduction in cardiovascular outcomes in 7,437 patients with broader CKD spectrum 2, 4

A prespecified subgroup analysis revealed that in patients without symptomatic HFrEF, finerenone reduces the risk for new-onset heart failure and improves heart failure outcomes. 2 Benefits were consistent regardless of baseline cardiovascular disease history. 4

Common Pitfalls to Avoid

• Do not use if baseline potassium ≥4.8 mmol/L 1
• Do not use if eGFR <25 mL/min/1.73 m² 1
• Exercise caution when combining with ACE inhibitors or ARBs due to increased hyperkalemia risk, though this combination was standard in the trials 3, 4
• Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease 3
• Remember that finerenone should be used irrespective of glycemic control needs—the indication is for cardiorenal protection, not glucose lowering 2