What is the recommended dosage of finerenone (generic name) for patients with chronic kidney disease?

Finerenone Dosing for Chronic Kidney Disease

For patients with chronic kidney disease and type 2 diabetes, initiate finerenone at 10 mg once daily if eGFR is 25-60 mL/min/1.73 m², or 20 mg once daily if eGFR is ≥60 mL/min/1.73 m², with dose uptitration to 20 mg after one month if serum potassium remains ≤4.8 mmol/L. 1, 2

Initial Dose Selection Based on eGFR

The starting dose is determined by baseline kidney function:

• eGFR 25-60 mL/min/1.73 m²: Start with 10 mg once daily 1, 3
• eGFR ≥60 mL/min/1.73 m²: Start with 20 mg once daily 1, 3
• eGFR <25 mL/min/1.73 m²: Do not use finerenone - the landmark trials excluded this population and there is no established dosing or safety data for end-stage renal disease 3

Dose Uptitration Protocol

After one month of treatment, increase the dose from 10 mg to 20 mg daily if all of the following criteria are met: 1, 3

• Serum potassium remains ≤4.8 mmol/L 1
• eGFR is stable 1
• Medication is well-tolerated 3

Potassium-Based Dose Adjustments

Finerenone dosing must be adjusted based on serum potassium levels using this algorithm: 1

Potassium ≤4.8 mmol/L:

• Continue current dose (10 mg or 20 mg) 1
• Monitor potassium every 4 months 1
• Consider uptitration if on 10 mg daily 1

Potassium 4.9-5.5 mmol/L:

• Continue current dose 1
• Monitor potassium every 4 months 1

Potassium >5.5 mmol/L:

• Hold finerenone 1, 3
• Adjust diet or concomitant medications to mitigate hyperkalemia 1
• Recheck potassium 1
• Restart at 10 mg daily when potassium returns to ≤5.0 mmol/L 1, 3

Monitoring Schedule

Baseline requirements before initiation: 1, 3

• Serum potassium must be ≤4.8 mmol/L 1
• Verify eGFR ≥25 mL/min/1.73 m² 1
• Confirm albuminuria (UACR ≥30 mg/g) 1, 2

After initiation: 1, 3

• Check potassium at 1 month after starting 1
• Then monitor potassium every 4 months 1
• Monitor renal function at 4 weeks, especially if eGFR <60 mL/min/1.73 m² 4

Patient Eligibility Criteria

Finerenone is appropriate for patients meeting all of these criteria: 1, 2

• Type 2 diabetes with chronic kidney disease 1
• eGFR ≥25 mL/min/1.73 m² 1, 3
• Persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated RAS inhibitor therapy 1, 2
• Baseline serum potassium ≤4.8 mmol/L 1

Administration Considerations

• Finerenone can be taken with or without food - high-fat meals increase AUC by 21% but decrease Cmax by 19%, which is not clinically significant 5
• Once-daily morning dosing provides persistent 24-hour blood pressure reduction despite the short half-life 6
• Finerenone can be safely combined with SGLT2 inhibitors for additive benefits 2, 7
• pH-modifying medications (proton pump inhibitors, antacids) do not require dose adjustment 5

Common Pitfalls to Avoid

Do not initiate finerenone if: 3

• eGFR <25 mL/min/1.73 m² or patient is on dialysis 3
• Baseline potassium >4.8 mmol/L 1
• Patient has not been optimized on maximum tolerated RAS inhibitor first 3

Key safety consideration: Hyperkalemia occurs in 10.8% of patients versus 5.3% with placebo, but discontinuation rates remain low at 2.3% versus 0.9% 2, 3. The dose titration protocol and potassium monitoring effectively manage this risk 8.