Finerenone Dosing in Impaired Renal Function
For patients with impaired renal function, start finerenone at 10 mg once daily if eGFR is 25-60 mL/min/1.73 m², and 20 mg once daily if eGFR is >60 mL/min/1.73 m², with uptitration to 20 mg after 1 month if serum potassium remains ≤4.8 mmol/L. 1
Initial Dosing Based on eGFR
The dosing algorithm is straightforward and based on baseline kidney function:
- eGFR >60 mL/min/1.73 m²: Start at 20 mg once daily 1
- eGFR 25-60 mL/min/1.73 m²: Start at 10 mg once daily 1
- eGFR <25 mL/min/1.73 m²: Finerenone can be initiated at eGFR ≥25 mL/min/1.73 m² per trial eligibility, though it may be continued below this threshold if potassium remains acceptable 1
Potassium Requirements for Initiation
Before starting finerenone, verify that serum potassium meets safety thresholds:
The more conservative 4.8 mmol/L threshold from the FIDELIO-DKD and FIGARO-DKD trials provides the strongest safety evidence. 1
Dose Uptitration Protocol
After 1 month of treatment, consider uptitration from 10 mg to 20 mg daily if: 1
This uptitration strategy was used successfully in the pivotal trials, with the goal of achieving the target dose of 20 mg daily for maximal cardiovascular and renal protection. 1
Ongoing Potassium Monitoring
Potassium surveillance is critical to safe finerenone use:
- Check potassium 4 weeks after any dose change 1
- Continue regular monitoring throughout treatment 1
- Continue finerenone if potassium remains ≤5.5 mmol/L 1
- Withhold finerenone if potassium rises >5.5 mmol/L 1
- Restart at 10 mg daily when potassium returns to ≤5.0 mmol/L 1
Pharmacokinetic Considerations in Renal Impairment
Exposure to finerenone increases with worsening renal function, though this is already accounted for in the dosing algorithm:
- Mild renal impairment (CrCl 50-80 mL/min): No significant change in exposure 2
- Moderate renal impairment (CrCl 30-<50 mL/min): 57% increase in unbound finerenone exposure 2
- Severe renal impairment (CrCl <30 mL/min): 47% increase in unbound finerenone exposure 2
The lower starting dose of 10 mg in patients with eGFR 25-60 mL/min/1.73 m² compensates for this increased exposure and maintains safety. 2
Critical Safety Considerations
Hyperkalemia is the primary safety concern, but discontinuation rates remain low:
- In FIDELIO-DKD, hyperkalemia led to discontinuation in only 2.3% of finerenone patients versus 0.9% of placebo patients 1
- In FIGARO-DKD, only 1.2% discontinued due to hyperkalemia 1, 3
- No deaths related to hyperkalemia occurred in either trial 1, 3
The dose titration protocol based on potassium monitoring effectively manages this risk. 4
Patient Eligibility Beyond eGFR
Finerenone should only be initiated in patients who meet these additional criteria:
- Type 2 diabetes with chronic kidney disease 1
- Albuminuria (UACR ≥30 mg/g) despite standard care 1
- Already on maximum tolerated dose of RAS inhibitor (ACE inhibitor or ARB) 1
- Normal serum potassium as defined above 1
Continuation Below eGFR 25 mL/min/1.73 m²
While initiation requires eGFR ≥25 mL/min/1.73 m², finerenone can be continued if eGFR declines below this threshold during treatment, provided potassium remains acceptable and the drug is tolerated. 1 This allows for ongoing cardiorenal protection in patients with progressive disease.
Combination with SGLT2 Inhibitors
Recent evidence supports combining finerenone with SGLT2 inhibitors for additive benefit:
- The CONFIDENCE trial demonstrated that combination therapy with finerenone plus empagliflozin reduced albuminuria 29% more than finerenone alone and 32% more than empagliflozin alone 5
- No unexpected adverse events occurred with combination therapy 5
- This supports the ADA/KDIGO recommendation to layer finerenone onto existing SGLT2 inhibitor therapy 1, 6