What is the recommended use and dosage of finrenone (mineralocorticoid receptor antagonist) in patients with chronic kidney disease (CKD) and heart failure?

Finerenone Use in Chronic Kidney Disease and Heart Failure

Direct Recommendation

Finerenone should be initiated at 10-20 mg once daily in adults with type 2 diabetes and CKD (eGFR ≥25 mL/min/1.73 m²) who have persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated RAS inhibitor therapy, with baseline potassium ≤4.8 mmol/L. 1, 2

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Patient Selection Criteria

Eligible patients must meet ALL of the following:

• Type 2 diabetes with chronic kidney disease 1, 2
• eGFR ≥25 mL/min/1.73 m² (CKD stages 2-4) 1, 2
• Persistent albuminuria (UACR ≥30 mg/g) despite optimal therapy 1, 2
• Baseline serum potassium ≤4.8 mmol/L 1, 2
• Already on maximum tolerated dose of ACE inhibitor or ARB 1, 3

Absolute contraindications:

• End-stage renal disease or dialysis 1
• eGFR <25 mL/min/1.73 m² 1
• Baseline potassium >4.8 mmol/L 1, 2

The landmark FIDELIO-DKD and FIGARO-DKD trials specifically excluded patients with eGFR <25 mL/min/1.73 m², and no safety or dosing data exist for this population. 1

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Treatment Sequencing Algorithm

Follow this stepwise approach:

1. First-line: Maximize RAS inhibitor (ACE inhibitor or ARB) to highest tolerated dose 1, 3

2. Second-line: Add SGLT2 inhibitor—this should be prioritized over finerenone due to larger effects on kidney and cardiovascular outcomes 1

3. Third-line: Add finerenone if:

   • SGLT2 inhibitor is not tolerated, OR
   • Persistent albuminuria despite SGLT2 inhibitor therapy 1

4. Combination therapy: Finerenone can be used alongside SGLT2 inhibitors with potentially additive benefits 2, 3

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Dosing Protocol

Initial dose determination 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 after 1 month: 1

• If serum potassium remains ≤4.8 mmol/L AND eGFR is stable AND medication is well-tolerated
• Increase from 10 mg to 20 mg once daily

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Potassium Monitoring and Management

Critical monitoring schedule: 1, 2

• Verify potassium ≤4.8 mmol/L before initiation
• Check at 4 weeks after starting
• Monitor regularly throughout treatment

Hyperkalemia management algorithm: 1

• Potassium ≤5.5 mmol/L: Continue finerenone
• Potassium >5.5 mmol/L: Withhold finerenone
• Restart criteria: When potassium returns to ≤5.0 mmol/L, restart at 10 mg daily

Hyperkalemia occurred in 10.8% of finerenone patients versus 5.3% with placebo in trials, but discontinuation rates remained low at 2.3%. 1, 2 This represents a manageable safety concern with proper monitoring. 2

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Clinical Benefits

Cardiovascular outcomes: 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 (HR 0.71,95% CI 0.56-0.90)

Renal outcomes: 2, 3

• 36% reduction in progression to end-stage kidney disease (HR 0.64,95% CI 0.41-0.995)
• Significant reduction in urine albumin-to-creatinine ratio 5

The cardiovascular benefit was primarily driven by reduction in heart failure hospitalization, making finerenone particularly valuable in patients at high risk for this outcome. 4, 6

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Heart Failure Considerations

Finerenone provides consistent benefits across kidney function categories: 6

• Benefits observed regardless of baseline eGFR (≥60 vs <60 mL/min/1.73 m²)
• Benefits observed regardless of baseline UACR (<300 vs ≥300 mg/g)
• Lowest event rates in patients with eGFR ≥60 mL/min/1.73 m² and UACR <300 mg/g, but relative risk reduction consistent across all subgroups

Recent evidence from FINEARTS-HF demonstrates efficacy in heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), expanding finerenone's role beyond CKD-T2D. 7

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Common Pitfalls to Avoid

Do not initiate finerenone if: 1

• Patient has not been optimized on maximum tolerated RAS inhibitor first
• Baseline potassium is not verified to be ≤4.8 mmol/L
• eGFR is <25 mL/min/1.73 m² or patient is approaching dialysis

Do not skip SGLT2 inhibitor: 1

• SGLT2 inhibitors should generally be prioritized before finerenone due to larger magnitude of benefit
• Finerenone is most appropriate when SGLT2 inhibitors are contraindicated, not tolerated, or insufficient

Do not neglect potassium monitoring: 1, 2

• Regular monitoring is essential throughout treatment, not just at initiation
• Have a clear protocol for dose adjustment or temporary discontinuation based on potassium levels