What alternative to finerenone, that does not reduce renal potassium excretion, can a patient with hyperkalemia taking Veltassa (patiromer) use?

Alternative to Finerenone for Patients with Hyperkalemia on Patiromer

SGLT2 inhibitors (sodium-glucose cotransporter-2 inhibitors) are the optimal alternative to finerenone for patients with hyperkalemia taking patiromer, as they provide similar cardiovascular and renal benefits without reducing renal potassium excretion and may actually reduce hyperkalemia risk. 1

Why SGLT2 Inhibitors Are the Best Alternative

Mechanism and Potassium Effects

• SGLT2 inhibitors do not impair renal potassium excretion and may actually facilitate potassium elimination through increased distal sodium delivery to the collecting duct 1
• Unlike finerenone (a mineralocorticoid receptor antagonist that blocks aldosterone-mediated potassium excretion), SGLT2 inhibitors work by blocking glucose reabsorption in the proximal tubule without affecting potassium handling 1
• SGLT2 inhibitors are associated with lower hyperkalemia risk compared to MRAs, with PARADIGM-HF showing reduced hyperkalemia with sacubitril/valsartan (which has similar sodium-potassium dynamics) 1

Comparable or Superior Benefits to Finerenone

Cardiovascular outcomes:

• SGLT2 inhibitors reduce heart failure hospitalizations by 31% in patients with type 2 diabetes, similar to finerenone's cardiovascular benefits 1
• DAPA-HF and EMPEROR-Reduced trials demonstrated mortality and morbidity reduction in HFrEF patients comparable to MRA benefits 1

Renal outcomes:

• SGLT2 inhibitors slow CKD progression and reduce albuminuria, with DAPA-CKD showing benefit at eGFR >25 mL/min/1.73 m² and UACR >200 mg/g 1
• The KDIGO 2022 guidelines prioritize SGLT2 inhibitors over finerenone as the next step after baseline ACE inhibitor/ARB therapy due to larger effect sizes on both kidney and cardiovascular outcomes 1

Specific SGLT2 Inhibitor Recommendations

First-line choices:

• Dapagliflozin 10 mg daily or empagliflozin 10 mg daily (can increase to 25 mg) for patients with eGFR ≥20 mL/min/1.73 m² 1
• These agents can be initiated at eGFR as low as 20 mL/min/1.73 m² based on EMPEROR trials and DAPA-CKD subgroup analyses 1

Dosing considerations:

• Start at lower eGFR thresholds (≥20 mL/min/1.73 m²) compared to finerenone's contraindication at eGFR <25 mL/min/1.73 m² 1
• No dose adjustment needed for potassium levels, unlike finerenone which requires potassium <5.0 mEq/L for initiation 1

Clinical Algorithm for Your Patient

Step 1: Verify Suitability

• Confirm eGFR ≥20 mL/min/1.73 m² (SGLT2 inhibitors effective down to this level) 1
• Check for contraindications: type 1 diabetes without established CVD, diabetic ketoacidosis history, or severe volume depletion 1
• Continue patiromer as SGLT2 inhibitors do not increase hyperkalemia risk and may allow eventual patiromer dose reduction 2, 3

Step 2: Initiate SGLT2 Inhibitor

• Start dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily 1
• Maintain current ACE inhibitor/ARB therapy at maximum tolerated dose 1
• No need to hold or reduce patiromer during SGLT2 inhibitor initiation 2

Step 3: Monitor

• Check potassium and renal function at 1 week, then 4 weeks, then every 3-6 months 1
• Monitor for volume depletion, particularly in patients on loop diuretics 1
• Expect stable or improved potassium levels with SGLT2 inhibitor therapy 1

Step 4: Consider Patiromer Adjustment

• If potassium remains consistently <4.5 mEq/L for 3 months, consider reducing patiromer dose by 8.4 g 2, 3
• Continue monitoring potassium weekly for 1 month after any patiromer dose reduction 2

Why Not Other Alternatives?

GLP-1 receptor agonists:

• Provide cardiovascular benefits but do not have the same magnitude of renal protection as SGLT2 inhibitors or finerenone 1
• Should be considered as third-line therapy after SGLT2 inhibitors if glycemic targets not met 1

Steroidal MRAs (spironolactone/eplerenone):

• Cause more hyperkalemia than finerenone (3-4% discontinuation rate vs. 2.3% with finerenone) 1
• Would worsen your patient's hyperkalemia management challenge 1

Sacubitril/valsartan (ARNI):

• Provides HFrEF benefits but increases hyperkalemia risk similar to ARBs 1
• Not appropriate for patients already struggling with hyperkalemia 1

Critical Pitfall to Avoid

Do not discontinue patiromer when starting SGLT2 inhibitors — while SGLT2 inhibitors reduce hyperkalemia risk, your patient is already on patiromer for a reason (likely recurrent hyperkalemia on RAAS inhibitors). Maintain patiromer initially and only reduce dose if potassium trends consistently low over 3+ months 2, 3

Combination Therapy Consideration

If additional benefit needed beyond SGLT2 inhibitor:

• The KDIGO 2025 guidelines suggest finerenone can be added to SGLT2 inhibitors for patients with persistent albuminuria despite SGLT2 inhibitor therapy 1
• However, this would require aggressive potassium monitoring (weekly for first month) and likely continued patiromer therapy 1
• The CONFIDENCE trial showed combination empagliflozin + finerenone did not significantly increase hyperkalemia risk compared to finerenone alone, but 18.8% still developed hyperkalemia on finerenone 4