Is a Type 2 diabetic patient with normal estimated Glomerular Filtration Rate (eGFR) but elevated albumin/creatinine ratio a candidate for Kerendia (finerenone)?

Yes, this patient is a candidate for Kerendia (finerenone)

A Type 2 diabetic patient with normal eGFR but elevated albumin/creatinine ratio meets the criteria for finerenone therapy, provided the eGFR is ≥25 mL/min/1.73 m² and serum potassium is ≤4.8 mmol/L. 1, 2

Patient Eligibility Criteria

This patient fits the evidence-based indication for finerenone based on the following:

• Albuminuria presence is the key criterion: The 2024 ADA guidelines specifically recommend nonsteroidal mineralocorticoid receptor antagonists (finerenone) for patients with CKD and albuminuria who are at increased risk for cardiovascular events or CKD progression, with eGFR ≥25 mL/min/1.73 m². 1

• Normal eGFR does not exclude treatment: The landmark FIGARO-DKD trial included patients with eGFR up to 90 mL/min/1.73 m² and demonstrated efficacy even in those with preserved kidney function but elevated albuminuria. 2, 3

• Albuminuria threshold: Finerenone is indicated for patients with UACR ≥30 mg/g (any degree of albuminuria), which this patient has by definition of "elevated albumin/creatinine ratio." 2, 3

Treatment Sequencing Algorithm

Before initiating finerenone, follow this stepwise approach:

1. Optimize RAS inhibitor first: Ensure the patient is on maximum tolerated dose of ACE inhibitor or ARB, as this is foundational therapy. 1, 2

2. Add SGLT2 inhibitor as second-line: The 2024 ADA guidelines prioritize SGLT2 inhibitors over finerenone due to larger effects on kidney and cardiovascular outcomes. 1, 2

3. Consider finerenone as third-line or alternative: Add finerenone if:

   • Persistent albuminuria despite SGLT2 inhibitor 2
   • SGLT2 inhibitor intolerance or contraindication 2
   • Additional cardiovascular risk reduction needed 1

4. Combination therapy is supported: Recent evidence from the CONFIDENCE trial demonstrates that simultaneous use of finerenone plus empagliflozin produces a 29-32% greater reduction in albuminuria compared to either agent alone, without unexpected adverse events. 4

Dosing Based on eGFR

• eGFR >60 mL/min/1.73 m²: Start finerenone 20 mg once daily 2
• eGFR 25-60 mL/min/1.73 m²: Start finerenone 10 mg once daily, uptitrate to 20 mg after 1 month if potassium ≤4.8 mmol/L 2
• eGFR <25 mL/min/1.73 m²: Do not initiate finerenone (no safety or efficacy data) 2

Pre-Treatment Requirements

Before prescribing finerenone, verify:

• Serum potassium ≤4.8 mmol/L: This is mandatory before initiation 2, 1
• On maximum tolerated RAS inhibitor: ACE inhibitor or ARB must be optimized first 2, 1
• No contraindications: Avoid in patients with baseline potassium >4.8 mmol/L or concomitant strong CYP3A4 inhibitors 2

Monitoring Protocol

After initiating finerenone:

• Check potassium and creatinine at 1 month: Before any dose uptitration 2
• Continue monitoring regularly: The 2024 ADA guidelines recommend periodic monitoring when using mineralocorticoid receptor antagonists 1
• Withhold if potassium >5.5 mmol/L: Restart at 10 mg when potassium returns to ≤5.0 mmol/L 2, 5
• Do not discontinue for eGFR decreases <30%: Expected hemodynamic changes are not pathological 5

Evidence for Cardiovascular and Renal Benefits

The rationale for treating this patient includes:

• Albuminuria reduction mediates outcomes: In pooled FIDELIO-DKD and FIGARO-DKD data, early albuminuria reduction accounted for 84% of the treatment effect on kidney outcomes and 37% on cardiovascular outcomes. 6

• Proven CKD progression reduction: Finerenone reduces the risk of kidney failure by 36% and the composite kidney outcome (kidney failure, ≥57% eGFR decline, or renal death) by 18%. 3, 5

• Cardiovascular protection: Finerenone reduces cardiovascular death or heart failure hospitalization by 31% and the composite of cardiovascular death, nonfatal MI, or nonfatal stroke by 20%. 1

Common Pitfalls to Avoid

• Do not wait for eGFR decline: Albuminuria alone, even with normal eGFR, indicates kidney injury and increased cardiovascular risk requiring intervention. 1, 6

• Do not skip RAS inhibitor optimization: Finerenone should not replace but rather complement RAS blockade. 2, 1

• Do not overreact to mild potassium elevations: Hyperkalemia leading to discontinuation occurred in only 2.3% of patients in FIDELIO-DKD. 5

• Do not discontinue prematurely for creatinine increases: Increases up to 30% without volume depletion are expected and should not prompt discontinuation. 1, 5