Finerenone in Heart Failure: Role and Clinical Application
Finerenone is indicated for patients with type 2 diabetes and chronic kidney disease (CKD) with albuminuria to reduce cardiovascular events including heart failure hospitalization, and based on the 2025 FINEARTS-HF trial, it now has an expanded role in heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). 1, 2
Primary Indication: Type 2 Diabetes with CKD
Finerenone should be prescribed at 10-20 mg once daily for adults with type 2 diabetes and CKD who have persistent albuminuria (ACR ≥30 mg/g) despite maximum tolerated renin-angiotensin system inhibitor therapy, with eGFR ≥25 mL/min/1.73 m² and serum potassium <4.8 mEq/L. 1, 3
Cardiovascular Benefits in Diabetic CKD
The evidence from FIGARO-DKD and FIDELIO-DKD trials demonstrates robust heart failure benefits:
- Reduces heart failure hospitalization by 29% (HR 0.71,95% CI 0.56-0.90) 4, 5
- Reduces composite cardiovascular outcomes (CV death, nonfatal MI, nonfatal stroke, or HF hospitalization) by 13-14% (HR 0.86-0.87) 6, 4
- Prevents new-onset heart failure by 32% (HR 0.68,95% CI 0.50-0.93) in patients without prior HF history 5
- Reduces recurrent heart failure hospitalizations by 21% (HR 0.79,95% CI 0.64-0.96) 7
These benefits are consistent across all baseline kidney function categories (eGFR <60 or ≥60 mL/min/1.73 m²) and albuminuria levels (UACR <300 or ≥300 mg/g). 7
Dosing Algorithm
Start with 10 mg once daily if eGFR 25-60 mL/min/1.73 m², or 20 mg once daily if eGFR >60 mL/min/1.73 m². 3
- Check serum potassium at baseline (must be <4.8 mmol/L to initiate) 3
- Recheck potassium after 4 weeks 3
- Uptitrate to 20 mg daily if potassium remains <4.8 mmol/L 3
- Withhold if potassium >5.5 mmol/L; restart at 10 mg when potassium ≤5.0 mmol/L 3
Therapeutic Positioning in Treatment Algorithm
The American Diabetes Association guidelines establish a clear hierarchy for cardiorenal protection: 6
- First-line: SGLT2 inhibitors or GLP-1 receptor agonists (regardless of metformin use or glycemic control needs) 6
- Second-line: Add finerenone if albuminuria persists despite SGLT2 inhibitor, or if SGLT2 inhibitor is not tolerated 3
- Combination therapy: Finerenone can be added to RAS inhibitor + SGLT2 inhibitor for complementary cardiorenal protection 3
The American Heart Association supports combining finerenone with SGLT2 inhibitors for potentially additive benefits. 1
Expanded Role: HFmrEF and HFpEF
The 2025 FINEARTS-HF trial established finerenone as an evidence-based therapy for heart failure with mildly reduced or preserved ejection fraction, showing significantly lower rates of worsening heart failure events and cardiovascular death versus placebo. 2
This represents a major advancement, as steroidal MRAs (spironolactone, eplerenone) have highest-level guideline recommendations only for HF with reduced ejection fraction, not HFpEF/HFmrEF. 2
Safety Monitoring: Hyperkalemia Management
Hyperkalemia is the primary adverse effect requiring vigilant monitoring. 1, 4
- Incidence: 10.8-14% with finerenone vs. 5.3-6.9% with placebo 4, 7
- Severe hyperkalemia requiring discontinuation: only 1.2-1.7% 3, 4
- No deaths related to hyperkalemia occurred in major trials 4
- Monitor potassium regularly throughout treatment 1
Clinical Pitfalls to Avoid
Do not delay finerenone initiation waiting for "perfect" glycemic control—cardiovascular and renal benefits are independent of glucose-lowering effects. 6
Do not withhold finerenone due to concerns about adding another medication to RAS inhibitor + SGLT2 inhibitor—the combination provides complementary mechanisms of cardiorenal protection with acceptable safety profile. 3
Do not use finerenone as a substitute for SGLT2 inhibitors—SGLT2 inhibitors should be prioritized first due to larger effect sizes on both kidney and cardiovascular outcomes. 3
Do not forget that finerenone reduces heart failure progression even in patients without established heart failure at baseline—consider it for primary prevention of incident HF in high-risk diabetic CKD patients. 5