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

Finerenone for Chronic Kidney Disease and Heart Failure

Finerenone should be initiated at 10-20 mg once daily in 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, heart failure hospitalizations, and CKD progression. 1

Patient Selection Criteria

Before initiating finerenone, verify the following eligibility requirements:

• Type 2 diabetes with chronic kidney disease (CKD stages 2-4) 1
• eGFR ≥25 mL/min/1.73 m² - do not use in end-stage renal disease or dialysis patients 2
• Persistent albuminuria (UACR ≥30 mg/g) despite optimal therapy 1
• Serum potassium ≤4.8 mmol/L at baseline 1
• Already on maximum tolerated dose of ACE inhibitor or ARB 2

Treatment Sequencing Algorithm

The evidence establishes a clear hierarchy for cardiorenal protection 3:

1. First-line foundation therapy: Maximize RAS inhibitor (ACE inhibitor or ARB) dose 2
2. Second-line priority: Add SGLT2 inhibitor (larger effects on kidney and cardiovascular outcomes) 2
3. Third-line consideration: Add finerenone for patients with persistent albuminuria despite SGLT2 inhibitor, or if SGLT2 inhibitor is not tolerated 2

Finerenone can be combined with SGLT2 inhibitors for potentially additive benefits - the FIDELIO-DKD trial included 4.5% of patients on SGLT2 inhibitors, and recent real-world data shows 93.5% of finerenone patients were successfully treated with concomitant SGLT2 inhibitor therapy 4, 5

Dosing Protocol

Initial Dose Selection

Base the starting dose on eGFR 1:

• eGFR 25-60 mL/min/1.73 m²: Start 10 mg once daily 4, 1
• eGFR >60 mL/min/1.73 m²: Start 20 mg once daily 4, 1

Dose Uptitration

After 1 month of treatment, increase from 10 mg to 20 mg once daily if 4, 2:

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

Potassium Monitoring and Management

Hyperkalemia is the primary safety concern, occurring in 10.8% of finerenone patients versus 5.3% with placebo, but severe hyperkalemia requiring discontinuation occurs in only 1.2% 1, 3

Monitoring Schedule

• Baseline: Verify potassium ≤4.8 mmol/L before starting 1
• 4 weeks after initiation: Check potassium and eGFR 3
• Throughout treatment: Regular monitoring 1

Hyperkalemia Management Algorithm 2

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

Real-world data confirms safety: in a prospective cohort, potassium increased modestly from 4.2 to 4.4 mmol/L at 4 weeks and stabilized thereafter, with only one patient (3.2%) experiencing hyperkalaemia requiring hospitalization 5

Clinical Benefits

The evidence demonstrates substantial cardiorenal protection:

Cardiovascular Outcomes

• 14% reduction in composite cardiovascular death, nonfatal MI, nonfatal stroke, and heart failure hospitalization (HR 0.86-0.87) 1, 3
• 29% reduction in heart failure hospitalization (HR 0.71) - the primary driver of cardiovascular benefit 1, 3
• 29% reduction in new-onset atrial fibrillation (HR 0.71) 6

Renal Outcomes

• 36% reduction in progression to end-stage kidney disease (HR 0.64) 4, 1
• 18% reduction in composite kidney failure, sustained ≥40% eGFR decline, or renal death (HR 0.82) 4
• Significant reduction in albuminuria (mean difference -0.30) 7

Heart Failure Specific Benefits

Real-world echocardiographic data in patients with HFpEF/HFmrEF (present in 71% of DKD patients) shows finerenone improves cardiac structure and function 5:

• Left atrial volume index decreased from 31.2 to 26.6 mL/m² at 6 months
• E/e' ratio improved from 11.9 to 9.9 at 6 months

Critical Exclusions and Contraindications

Do not initiate finerenone if 2:

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

The landmark FIDELIO-DKD and FIGARO-DKD trials specifically excluded patients with eGFR <25 mL/min/1.73 m², establishing no safety or efficacy data for this population 2

Common Pitfalls to Avoid

• Starting finerenone before maximizing RAS inhibitor therapy - this is the required foundation 2
• Failing to check potassium at 4 weeks - the critical monitoring timepoint when potassium peaks 5
• Avoiding combination with SGLT2 inhibitors - these can be safely combined with additive benefits 1, 5
• Using in patients with eGFR <25 mL/min/1.73 m² - no evidence supports this, and hyperkalemia risk is substantially higher 2
• Discontinuing prematurely for mild hyperkalemia - only potassium >5.5 mmol/L requires temporary withholding 2