When to Initiate Finerenone in CKD and Type 2 Diabetes
Initiate finerenone in adults with type 2 diabetes who have persistent albuminuria (≥30 mg/g) despite maximum tolerated RAS inhibitor therapy, eGFR ≥25 mL/min/1.73 m², and normal serum potassium (≤4.8 mmol/L). 1
Patient Selection Criteria
Required Baseline Characteristics
- eGFR ≥25 mL/min/1.73 m² - Do not initiate if eGFR <25 mL/min/1.73 m² as this population was excluded from landmark trials and has no established safety data 2
- Albuminuria ≥30 mg/g despite being on maximum tolerated dose of ACE inhibitor or ARB 1
- Serum potassium ≤4.8 mmol/L at baseline - this is a strict requirement before initiation 1, 2
- Type 2 diabetes with chronic kidney disease 1, 3
High-Risk Features That Support Initiation
- Persistent albuminuria despite standard-of-care therapies indicates high risk for CKD progression and cardiovascular events 1, 3
- Patients at highest risk include those with UACR 300-5,000 mg/g and eGFR 25-60 mL/min/1.73 m² 4
Treatment Sequencing Algorithm
First-Line Foundation Therapy
- Start with RAS inhibitor (ACE inhibitor or ARB) at maximum tolerated dose 1
Second-Line Add-On
- SGLT2 inhibitor should be prioritized over finerenone as the next step after RAS inhibitor because SGLT2 inhibitors have larger effects on reducing both kidney and cardiovascular outcomes 1
When to Choose Finerenone
Finerenone should be considered in two specific scenarios: 1
- SGLT2 inhibitor intolerance - Patient cannot tolerate an SGLT2 inhibitor
- Persistent albuminuria despite SGLT2 inhibitor - Patient remains with albuminuria despite being on both RAS inhibitor and SGLT2 inhibitor
Triple Therapy Option
- Finerenone may be added to both a RAS inhibitor and SGLT2 inhibitor for complementary cardiorenal protection in patients with persistent albuminuria 1, 3
Dosing Strategy
Initial Dose Selection
- eGFR 25-60 mL/min/1.73 m²: Start 10 mg once daily 3, 2
- eGFR >60 mL/min/1.73 m²: Start 20 mg once daily 3, 2
Dose Titration
- After 4 weeks, uptitrate from 10 mg to 20 mg daily if serum potassium remains <4.8 mmol/L and eGFR is stable 3, 2
Potassium Monitoring Protocol
Pre-Initiation
- Verify serum potassium ≤4.8 mmol/L before starting 1, 2
- Select patients with consistently normal serum potassium concentration 1
During Treatment
- Monitor serum potassium regularly after initiation 1
- Continue finerenone if potassium ≤5.5 mmol/L 2
- Withhold finerenone if potassium >5.5 mmol/L 2
- Restart at 10 mg daily when potassium returns to ≤5.0 mmol/L 2
Clinical Benefits Supporting Use
Cardiovascular Protection
- 13% reduction in composite cardiovascular endpoints (cardiovascular death, nonfatal MI, nonfatal stroke, or hospitalization for heart failure) 3, 5
- 29% reduction in heart failure hospitalizations 5, 6
- 32% reduction in new-onset atrial fibrillation 7
Kidney Protection
- 23% reduction in composite kidney outcomes (kidney failure, sustained ≥57% decrease in eGFR, or renal death) 3
- 36% reduction in progression to end-stage kidney disease 5
Critical Pitfalls to Avoid
Do Not Initiate If:
- eGFR <25 mL/min/1.73 m² or patient is on dialysis 2
- Baseline potassium >4.8 mmol/L 2
- Patient has not been optimized on maximum tolerated RAS inhibitor first 1
Common Implementation Error
- Starting finerenone before SGLT2 inhibitor trial - KDOQI guidelines explicitly prioritize SGLT2 inhibitors over finerenone due to superior outcomes 1