Which group of patients needs Kerendia (finerenone)?

Which Patients Need Kerendia (Finerenone)

Kerendia (finerenone) is indicated for 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. 1, 2

Specific Patient Criteria

Essential Requirements

• Type 2 diabetes with chronic kidney disease - this is the foundational requirement for finerenone therapy 3, 4
• eGFR ≥25 mL/min/1.73 m² - patients with eGFR <25 mL/min/1.73 m² or end-stage renal disease should NOT receive finerenone, as landmark trials excluded this population and no safety data exists 1
• Persistent albuminuria (UACR ≥30 mg/g) - albuminuria must be present despite optimal standard therapy 1, 2
• Serum potassium ≤4.8 mmol/L - this is a critical safety threshold that must be met before initiation 1, 5

Treatment Sequencing Algorithm

The American Diabetes Association and KDIGO guidelines establish a clear hierarchy 1:

1. First-line foundation: Maximum tolerated dose of ACE inhibitor or ARB 1
2. Second-line priority: SGLT2 inhibitor (preferred over finerenone due to larger effects on kidney and cardiovascular outcomes) 1
3. Third-line consideration: Finerenone for patients with:
   • Persistent albuminuria despite SGLT2 inhibitor therapy, OR
   • SGLT2 inhibitor intolerance 1

Dosing Based on Kidney Function

Initial Dose Selection

• eGFR 25-60 mL/min/1.73 m²: Start 10 mg once daily 1, 2
• eGFR >60 mL/min/1.73 m²: Start 20 mg once daily 1, 2

Dose Uptitration

• After 1 month, increase from 10 mg to 20 mg daily if serum potassium remains ≤4.8 mmol/L and eGFR is stable 1

Clinical Benefits Supporting Use

Finerenone provides substantial cardiorenal protection in this population 2, 6:

• 36% reduction in progression to end-stage kidney disease (HR 0.64) 2
• 14% reduction in composite cardiovascular outcomes (CV death, nonfatal MI, nonfatal stroke, or heart failure hospitalization; HR 0.86) 2
• 29% reduction in heart failure hospitalization (HR 0.71) 2, 5

These benefits are consistent across all eGFR and albuminuria categories within the approved range 6

Critical Exclusion Criteria

Do NOT initiate finerenone if 1:

• eGFR <25 mL/min/1.73 m²
• Patient is on dialysis or has end-stage renal disease
• Baseline potassium >4.8 mmol/L
• Patient has not been optimized on maximum tolerated RAS inhibitor first

Safety Monitoring Requirements

Potassium Monitoring Protocol

• Before initiation: Verify potassium ≤4.8 mmol/L 1, 5
• At 4 weeks: Recheck potassium after starting therapy 5
• Ongoing: Regular monitoring throughout treatment 1

Management of Hyperkalemia

• Potassium ≤5.5 mmol/L: Continue finerenone 1
• Potassium >5.5 mmol/L: Withhold finerenone 1
• Restart criteria: When potassium returns to ≤5.0 mmol/L, restart at 10 mg daily 1

The hyperkalemia risk with finerenone (10.8% vs 5.3% placebo) is manageable with proper monitoring, and severe hyperkalemia requiring discontinuation occurs in only 1.2-1.7% of patients 5

Common Clinical Pitfall

The most important pitfall is initiating finerenone before optimizing foundational therapies. Patients must already be on maximum tolerated RAS inhibitor therapy, and SGLT2 inhibitors should generally be prioritized over finerenone as the next step due to their superior overall cardiorenal benefits 1. Finerenone serves as an important addition for patients with persistent albuminuria despite these therapies or when SGLT2 inhibitors cannot be used.