The Non-Steroidal Mineralocorticoid Receptor Antagonist Finerenone: A New Option for Patients with Diabetic Kidney Disease

Allison S. Rembert, PharmD Candidate 2024
Adrian K. Baker, PharmD Candidate 2024
Joshua J. Neumiller, PharmD, CDCES, FADCES, FASCP

Department of Pharmacotherapy
College of Pharmacy and Pharmaceutical Sciences
Washington State University

A 55-year-old female with type 2 diabetes (T2D) and chronic kidney disease (CKD) presented to the ambulatory care clinic. Her T2D was previously managed with metformin plus an SGLT2 inhibitor, but the SGLT2 inhibitor was discontinued recently due to recurring yeast infections. Her primary care provider (PCP) referred her to pharmacy for a diabetes consult and evaluation for alternative agents (following discontinuation of the SGLT2 inhibitor) to slow progression of her CKD. 

The patient’s medication regimen at the time of the consult consisted of the following:

• Metformin 500 mg twice daily
• Insulin Glargine 16 units once daily in the morning
• Lisinopril 40 mg once daily
• Atorvastatin 40 mg once daily
• Multivitamin once daily

Recent pertinent laboratory values:

• A1C: 7.0%
• eGFR: 44 mL/min/1.73m²
• UACR: 420 mg/g
• Potassium: 3.7 mmol/L

According to both the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO), an SGLT2 inhibitor with evidence of kidney benefit is recommended for patients with T2D and CKD to mitigate kidney and cardiovascular risk.^1,2 The ADA additionally recommends use of a non-steroidal mineralocorticoid receptor antagonist (ns-MRA) to reduce CKD progression and cardiovascular events in patients with T2D and CKD.¹ Finerenone (Kerendia) is a ns-MRA approved to reduce the risk of sustained eGFR decline, end-stage kidney disease (ESKD), cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in adults with T2D and CKD.³ This indication was granted by the U.S. FDA based on findings from large outcome trials demonstrated kidney and cardiovascular benefit with finerenone in this population.^4,5 Considering the patient has been unable to tolerate an SGLT2 inhibitor, she does not require additional glucose-lowering at this time, and her potassium levels are in the normal range, we felt finerenone was a good option in this patient to address her kidney and cardiovascular risk.

Recommendations made: 

• Initiate finerenone 10 mg by mouth once daily; may consider titration to 20 mg once daily after 4 weeks based on potassium levels. 
• Monitor serum potassium 4 weeks after initiation and titrate per manufacturer recommendations.
• Monitor serum potassium 4 weeks following dose adjustments and throughout treatment to guide therapy. 

Lessons learned: 

• Finerenone (Kerendia) is a ns-MRA approved to mitigate kidney and cardiovascular risk in patients with T2D and CKD.
• Finerenone is recommended by the ADA to improve outcomes in patients with T2D and CKD in general, but also provides an option for patients unable to take or tolerate SGLT2 inhibitors.
• Patients receiving finerenone should undergo regular laboratory monitoring for serum potassium and eGFR to guide finerenone dose adjustments.

References:

1. American Diabetes Association Professional Practice Committee. 11. Chronic kidney disease and risk management: Standards of Medical Care in Diabetes – 2022. Diabetes Care 2022;45(Suppl. 1):S175-S184.

2. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020;98(4S):S1-S115.

3. Kerendia (finerenone) [Prescribing Information]. Bayer HealthCare Pharmaceuticals Inc. Whippany, NJ. July 2021.

4. Bakris GL, Agarwal R, Anker SD, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383:2219-2229.

5. Pitt B, Filippatos G, Agarwal R, et al. Cardiovascular events with finerenone in kidney disease and type 2 diabetes. N Engl J Med. 2021;385:2252-2263.