What is the recommended use and dosage of Finerenone (Finerenone) for patients with chronic kidney disease (CKD) and heart failure?

Finerenone for Chronic Kidney Disease and Heart Failure

Finerenone is recommended at 10-20 mg once daily for adults with type 2 diabetes and chronic kidney disease (eGFR ≥25 mL/min/1.73 m²) who have persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated renin-angiotensin system blockade, to reduce cardiovascular events and CKD progression. 1, 2

Patient Selection Criteria

Before initiating finerenone, verify the following eligibility requirements:

• Type 2 diabetes with CKD and albuminuria (UACR ≥30 mg/g) 1, 3
• eGFR ≥25 mL/min/1.73 m² (do not use if eGFR <25 or on dialysis) 3
• Serum potassium ≤4.8 mmol/L at screening 1, 3
• Already on maximum tolerated dose of ACE inhibitor or ARB 3

Exclude patients with:

• Heart failure with reduced ejection fraction 1
• Uncontrolled hypertension 1
• End-stage renal disease or dialysis 3
• Baseline potassium >4.8 mmol/L 3

Dosing Algorithm

Initial dose determination based on eGFR: 1, 3

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

Dose uptitration after 1 month: 1, 3

• Increase from 10 mg to 20 mg daily if:
  • Serum potassium remains ≤4.8 mmol/L
  • eGFR is stable
  • Medication is well-tolerated

Potassium Monitoring Protocol

Critical monitoring schedule to prevent hyperkalemia: 3

• Check potassium at baseline before starting
• Recheck at 4 weeks after initiation
• Continue regular monitoring throughout treatment

Management of elevated potassium: 3

• Potassium ≤5.5 mmol/L: Continue finerenone
• Potassium >5.5 mmol/L: Withhold finerenone temporarily
• Restart at 10 mg daily when potassium returns to ≤5.0 mmol/L

Clinical Benefits on Mortality and Morbidity

Cardiovascular outcomes: 1, 2, 4

• 14% reduction in composite cardiovascular death, nonfatal MI, nonfatal stroke, and heart failure hospitalization (HR 0.86,95% CI 0.78-0.95)
• 29% reduction in heart failure hospitalization specifically (HR 0.71,95% CI 0.56-0.90)
• 36% reduction in progression to end-stage kidney disease (HR 0.64,95% CI 0.41-0.995) 1

Renal outcomes: 1

• 23% reduction in composite kidney outcome of sustained ≥57% decrease in eGFR or renal death (HR 0.77,95% CI 0.67-0.88)
• Benefits demonstrated across the full spectrum of CKD severity (eGFR 25-90 mL/min/1.73 m²) 1

Combination Therapy Strategy

Finerenone complements SGLT2 inhibitors with potentially additive benefits and should be considered as second-line therapy for patients with persistent albuminuria already on SGLT2 inhibitors or GLP-1 receptor agonists. 2, 4 The FIDELIO-DKD trial included only 4.5% of patients on SGLT2 inhibitors, but current guidelines support combining these agents. 1

Safety Profile and Common Pitfalls

Hyperkalemia is the primary adverse effect: 1, 4

• Occurs in 10.8% with finerenone vs 5.3% with placebo 1
• Only 1.2% discontinue due to hyperkalemia 1, 4
• Risk is manageable with proper monitoring and dose adjustments 3

Critical pitfall to avoid: Do not initiate finerenone in patients approaching eGFR <25 mL/min/1.73 m², as there is no safety or efficacy data below this threshold, and these patients should be referred to nephrology for renal replacement therapy planning. 3

Additional Cardiovascular Benefits

Beyond the primary indications, finerenone reduces new-onset atrial fibrillation by 29% (HR 0.71,95% CI 0.53-0.94) in patients with CKD and type 2 diabetes, providing additional cardiovascular protection. 5 Recent evidence from FINEARTS-HF also demonstrates benefits in heart failure with preserved or mildly reduced ejection fraction, though this is not yet the primary indication. 6