Add Finerenone to Your Current Regimen
For a patient with impaired renal function and diabetes already on enalapril and dapagliflozin, add finerenone (a nonsteroidal mineralocorticoid receptor antagonist) if albuminuria persists ≥30 mg/g, eGFR ≥25 mL/min/1.73 m², and serum potassium is normal. This triple therapy approach provides the most comprehensive kidney and cardiovascular protection based on current evidence. 1
Rationale for Adding Finerenone
The 2022 KDIGO guidelines provide Grade 1A evidence that finerenone reduces kidney disease progression and cardiovascular events when added to maximal RAS inhibition (your enalapril) and SGLT2 inhibition (your dapagliflozin) in patients with type 2 diabetes and persistent albuminuria. 1
Key benefits of finerenone in the FIDELIO-DKD and FIGARO-DKD trials:
- 23% reduction in kidney composite outcome (kidney failure, >57% eGFR decrease, or kidney death; HR 0.77,95% CI 0.67-0.88) 1
- 20% reduction in kidney failure requiring dialysis or transplantation (HR 0.80,95% CI 0.64-0.99) 1
- Cardiovascular benefits in addition to kidney protection 1
Specific Eligibility Criteria for Finerenone
Check these parameters before initiating:
- Albuminuria (ACR) ≥30 mg/g (≥3 mg/mmol) despite maximal tolerated RAS inhibitor dose 1
- eGFR ≥25 mL/min/1.73 m² 1
- Normal serum potassium concentration 1
- Patient already on maximal tolerated dose of enalapril 1
Continue Your Current Medications
Enalapril (RAS blockade):
- Continue at maximal tolerated dose for patients with diabetes, hypertension, and albuminuria 1
- Monitor serum creatinine and potassium within 2-4 weeks of any dose adjustment 1
- Continue unless creatinine rises >30% within 4 weeks 1
Dapagliflozin (SGLT2 inhibitor):
- Continue 10 mg daily for kidney and cardiovascular protection even if eGFR falls below 20 mL/min/1.73 m² until dialysis initiation 1, 2
- Do not discontinue solely because eGFR <45 mL/min/1.73 m², as cardiovascular and renal benefits persist at lower eGFR levels 2
- Temporarily withhold during acute illness with reduced oral intake, fever, vomiting, or diarrhea 2
Additional Foundational Therapies
Statin therapy:
- Initiate high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) if not already prescribed, as all patients with diabetes and CKD require statin therapy regardless of baseline LDL 1
GLP-1 receptor agonist:
- Consider adding if additional glycemic control is needed or if eGFR <45 mL/min/1.73 m² where dapagliflozin's glucose-lowering efficacy diminishes 1
- Semaglutide reduced kidney disease progression by 36% in cardiovascular outcome trials 1
Critical Monitoring for Hyperkalemia
Finerenone increases hyperkalemia risk (14% vs 6.9% with placebo), but permanent discontinuation was rare (1.7% vs 0.6%) with no deaths from hyperkalemia over 3 years. 1
Management algorithm for hyperkalemia:
- Check potassium within 2-4 weeks after starting finerenone 1
- If hyperkalemia develops, first attempt management through: 1
- Moderate dietary potassium intake
- Initiate or increase diuretics
- Add sodium bicarbonate if metabolic acidosis present
- Consider gastrointestinal cation exchangers
- Reduce or stop finerenone only as last resort 1
Common Pitfalls to Avoid
Do not discontinue dapagliflozin when eGFR falls below 45 mL/min/1.73 m² – cardiovascular and renal protective benefits persist even when glycemic efficacy is lost. 2
Do not avoid finerenone solely due to concerns about combining with enalapril – the FIDELIO-DKD and FIGARO-DKD trials specifically studied finerenone added to maximal RAS inhibition, demonstrating safety and efficacy. 1
Do not withhold dapagliflozin for minor eGFR dips – an initial reversible eGFR decrease of 3-5 mL/min/1.73 m² within 4 weeks is expected and not an indication to discontinue. 1, 2
Monitoring Schedule
Every 3-6 months, reassess: 1
- Serum potassium (critical with triple therapy)
- Serum creatinine and eGFR
- Albuminuria (ACR)
- Blood pressure
- HbA1c
- Lipid panel