What is the indication for Finerenone (Finerenone) in adults with type 2 diabetes?

Finerenone Indication in Adults with Type 2 Diabetes

Finerenone is indicated for adults with type 2 diabetes and chronic kidney disease who have persistent albuminuria (≥30 mg/g) despite maximum tolerated renin-angiotensin system inhibitor therapy, with eGFR ≥25 mL/min/1.73 m² and serum potassium ≤4.8 mmol/L. 1, 2

Patient Selection Criteria

The following criteria must ALL be met before initiating finerenone:

• Type 2 diabetes with chronic kidney disease 1, 2
• eGFR ≥25 mL/min/1.73 m² (do not use if eGFR <25 or on dialysis) 1, 2
• Albuminuria ≥30 mg/g (≥3 mg/mmol) that persists despite standard therapy 1, 2
• Already on maximum tolerated dose of ACE inhibitor or ARB 1, 2
• Serum potassium ≤4.8 mmol/L at baseline 1, 2

Treatment Sequencing Algorithm

Follow this hierarchical approach for cardiorenal protection:

1. First-line foundation: Maximize RAS inhibitor (ACE inhibitor or ARB) 2, 3
2. Second-line priority: Add SGLT2 inhibitor (larger effects on kidney and cardiovascular outcomes than finerenone) 2, 3
3. Third-line consideration: Add finerenone if:
   • Patient cannot tolerate SGLT2 inhibitor, OR 2
   • Albuminuria persists despite SGLT2 inhibitor therapy 2
4. Combination therapy: Finerenone may be added to both RAS inhibitor AND SGLT2 inhibitor for complementary cardiorenal protection 1, 2

Dosing Protocol

Initial dose based on eGFR: 1, 2

• 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: 1, 2

• After 4 weeks, increase from 10 mg to 20 mg daily if serum potassium remains ≤4.8 mmol/L

Potassium Monitoring and Management

Monitoring schedule: 1, 2

• Check potassium at baseline (must be ≤4.8 mmol/L to initiate)
• Recheck at 1 month after initiation
• Then monitor every 4 months during maintenance

Management based on potassium levels: 1

Potassium Level	Action
≤4.8 mmol/L	Continue current dose or uptitrate to 20 mg if on 10 mg [1]
4.9-5.5 mmol/L	Continue current dose, monitor every 4 months [1]
>5.5 mmol/L	Hold finerenone, adjust diet/medications, recheck potassium, restart at 10 mg when ≤5.0 mmol/L [1,2]

Clinical Benefits Supporting This Indication

Finerenone provides dual cardiorenal protection in this population:

• Kidney protection: 23% reduction in composite kidney outcomes (kidney failure, sustained ≥57% decrease in eGFR, or renal death) 2
• Cardiovascular protection: 13% reduction in cardiovascular endpoints (CV death, nonfatal MI, nonfatal stroke, or heart failure hospitalization) 2
• Heart failure hospitalization: 29% reduction specifically 4

Target Population Characteristics

Finerenone is most appropriate for patients at high risk of CKD progression and cardiovascular events, specifically those with: 1, 2

• Persistent albuminuria despite optimized standard-of-care therapies
• Progressive kidney function decline
• History of or risk for cardiovascular events

Critical Safety Considerations

Hyperkalemia risk: 2, 4

• Occurs in 10.8-14% with finerenone vs. 5.3-6.9% with placebo
• Severe hyperkalemia requiring discontinuation: only 1.2-1.7% of patients
• Lower risk than steroidal MRAs (spironolactone/eplerenone)

Common pitfall to avoid: Do not initiate finerenone in patients who have not first been optimized on maximum tolerated RAS inhibitor therapy. 2, 3

Absolute contraindications: 2, 3

• eGFR <25 mL/min/1.73 m²
• End-stage renal disease or dialysis
• Baseline potassium >4.8 mmol/L