Finerenone (Kerendia) will be a new Rx for patients with chronic kidney disease (CKD) due to type 2 diabetes.
It's the first "nonsteroidal mineralocorticoid receptor antagonist"...and is approved to slow CKD progression and improve CV outcomes in these patients.
Finerenone is thought to limit fibrosis and inflammation in the kidneys and heart...by blocking effects of aldosterone.
Think of spironolactone or eplerenone as working similarly. But they're steroidal...and don't have evidence of improved CKD outcomes.
Adding once-daily finerenone to max ACEI or ARB doses slows CKD progression in about 1 in 30 patients over 2.5 years...mostly due to less risk of significant eGFR decline, not kidney failure or death.
It also reduces risk of CV events in about 1 in 56 patients...likely due to reducing heart failure hospitalizations.
But be aware of downsides. Finerenone causes hyperkalemia in up to 1 in 11 patients...shouldn't be started if eGFR is below 25 mL/min/1.73 m2...and costs about $570/month.
Expect finerenone to be saved as a last resort in patients with CKD due to type 2 diabetes. BP and glucose will continue to be optimized first...along with maximizing ACEI or ARB doses.
If a metformin add-on is needed, look for an SGLT2 inhibitor (empagliflozin, etc) or possibly a GLP-1 agonist (liraglutide, etc) to be used.
These meds help protect the kidneys...improve CV outcomes...and lower glucose. Finerenone doesn't lower glucose.
Don't anticipate that finerenone will be on your formulary. It's okay to hold during admission...missing a few doses isn't likely to affect outcomes.
At discharge, generally restart finerenone at the patient's home dose.
See our chart, Slowing Progression of Kidney Disease in Patients With Diabetes, for an evidence-based approach to treatment.
- N Engl J Med. 2020 Dec 3;383(23):2219-2229
- N Engl J Med. 2021 Aug 28. doi: 10.1056/NEJMoa2110956
- Diabetes Care. 2021 Jan;44(Suppl 1):S151-S167
- Medication pricing by Elsevier, accessed Oct 2021