In an adult hypertensive patient on finerenone (non‑steroidal mineralocorticoid receptor antagonist) who recently started semaglutide (Ozempic) for weight loss and now has hypotension (blood pressure 75/61 mm Hg), should finerenone be discontinued?

Should Finerenone Be Discontinued in This Patient?

Yes, finerenone should be discontinued immediately in this patient with symptomatic hypotension (blood pressure 75/61 mmHg) who recently started semaglutide and is losing weight.

Rationale for Discontinuation

Finerenone and Hypotension Risk

• Finerenone produces persistent blood pressure reductions over 24 hours despite its short half-life, with placebo-adjusted reductions in systolic blood pressure ranging from -8.3 to -11.2 mmHg in clinical trials 1
• In the FINEARTS-HF trial, finerenone significantly increased the risk of systolic blood pressure <100 mmHg (odds ratio 1.60; 95% CI: 1.38-1.85) and investigator-reported hypotension (odds ratio 1.67; 95% CI: 1.34-2.08) compared to placebo 2
• The current blood pressure of 75/61 mmHg represents severe hypotension that can compromise end-organ perfusion and increase fall risk 2

Semaglutide's Contribution to Blood Pressure Reduction

• GLP-1 receptor agonists like semaglutide (Ozempic) produce weight loss that independently lowers blood pressure by approximately 6.0/4.6 mmHg per 10 kg of weight loss 3
• The combination of ongoing weight loss from semaglutide and finerenone's persistent antihypertensive effect creates an additive blood pressure-lowering effect that has resulted in symptomatic hypotension 1, 3

Clinical Context: "Preventative" Indication

• The patient was placed on finerenone for "preventative medication for blood pressure," suggesting it was not initiated for a compelling indication such as chronic kidney disease with diabetes or heart failure 4, 5
• Without a specific cardiorenal indication, the risk-benefit ratio of continuing finerenone in the setting of severe hypotension is unfavorable 2

Immediate Management Steps

Discontinue Finerenone

• Stop finerenone immediately—do not attempt dose reduction, as even lower doses produce significant 24-hour blood pressure reductions 1
• Finerenone's short half-life means blood pressure should begin to recover within 24-48 hours after discontinuation 1

Monitor Blood Pressure Closely

• Recheck blood pressure within 2-4 days after stopping finerenone to assess recovery 2
• If blood pressure remains <90/60 mmHg after finerenone discontinuation, evaluate for other contributing factors (dehydration, other antihypertensive medications, adrenal insufficiency) 2

Continue Semaglutide

• Semaglutide should be continued for its metabolic benefits, as the hypotension is primarily attributable to the combination of weight loss and finerenone's antihypertensive effect 3
• As weight loss continues, blood pressure may stabilize at a lower baseline, which is generally beneficial for cardiovascular health 3

When to Consider Restarting Finerenone

Only If Compelling Indication Develops

• Finerenone should only be reintroduced if the patient develops chronic kidney disease with type 2 diabetes (eGFR 25-90 mL/min/1.73m² with albuminuria) or heart failure with mildly reduced or preserved ejection fraction 4, 5
• In such cases, restart only after blood pressure has stabilized at ≥110/70 mmHg for at least 2-4 weeks 2

Baseline Blood Pressure Requirements

• Patients with baseline systolic blood pressure <100 mmHg had attenuated treatment benefit from finerenone in FINEARTS-HF, suggesting lower blood pressure reduces the favorable risk-benefit ratio 2
• Do not restart finerenone if baseline blood pressure remains <110/70 mmHg after weight stabilization 2

Common Pitfalls to Avoid

• Do not attempt dose reduction of finerenone in the setting of severe hypotension—even 10 mg daily produces significant 24-hour blood pressure reductions of -8.3 mmHg systolic 1
• Do not discontinue semaglutide to preserve finerenone, as semaglutide provides proven metabolic benefits and the hypotension is reversible by stopping finerenone 3, 2
• Do not delay discontinuation while "monitoring"—a blood pressure of 75/61 mmHg requires immediate action to prevent syncope, falls, and end-organ hypoperfusion 2
• Do not restart finerenone without a specific cardiorenal indication (CKD with diabetes or heart failure), as it was initiated for "prevention" rather than treatment of established disease 4, 5