Finerenone for Hypertension: Not Indicated
Finerenone is not appropriate for treating hypertension alone and should not be used for this indication. Finerenone is FDA-approved exclusively for adults with type 2 diabetes and chronic kidney disease (CKD stages 2-4) who have persistent albuminuria (≥30 mg/g) despite maximum tolerated RAS inhibitor therapy 1, 2.
Why Finerenone Is Not a Hypertension Drug
Finerenone provides only modest blood pressure reduction (2-3 mmHg systolic), which is insufficient to justify its use as an antihypertensive agent 3.
The landmark trials (FIDELIO-DKD and FIGARO-DKD) enrolled patients specifically for diabetic kidney disease, not hypertension, and blood pressure lowering was a secondary effect, not the primary therapeutic goal 1, 4.
Major guidelines (KDIGO 2022, American Diabetes Association) explicitly designate finerenone for "T2D only", distinguishing it from therapies applicable to general hypertension management 1, 2.
Appropriate Indications for Finerenone
Finerenone should only be considered when all of the following criteria are met:
- Type 2 diabetes is present 1, 2
- eGFR is 25-90 mL/min/1.73 m² (CKD stages 2-4) 1, 2
- Persistent albuminuria (UACR ≥30 mg/g) despite standard therapy 1, 2
- Already on maximum tolerated dose of ACE inhibitor or ARB 1, 2
- Serum potassium ≤4.8 mmol/L 1, 2
Treatment Algorithm for Hypertension in CKD
If you have a patient with hypertension and CKD, follow this sequence:
- First-line: ACE inhibitor or ARB at maximum tolerated dose (especially if albuminuria is present) 1
- Add dihydropyridine calcium channel blocker and/or diuretic to achieve blood pressure targets 1
- Consider SGLT2 inhibitor (if diabetic) for additional cardiovascular and renal protection 1, 2
- Only then consider finerenone if the patient meets all criteria above (diabetic, persistent albuminuria, normal potassium) 1, 2
Steroidal MRAs for Resistant Hypertension
For resistant hypertension without diabetes, use spironolactone instead, which is the appropriate MRA for blood pressure control 1, 3.
Spironolactone can be used if eGFR ≥45 mL/min/1.73 m² and is specifically indicated for resistant hypertension 1, 3.
Spironolactone has higher affinity for renal tubules and stronger antihypertensive effects compared to finerenone 3, 5.
Critical Pitfall to Avoid
Do not extrapolate diabetic kidney disease evidence to non-diabetic hypertension patients, even if they have similar levels of kidney dysfunction 6. Finerenone's evidence base is exclusively in type 2 diabetes with CKD, and using it outside this population is inappropriate and not supported by clinical trial data 1, 2, 4.