CKD Nephroprotection Pregnancy: Contraindicated — animal data shows fetal harm; effective contraception required

Finerenone

Brand names: Kerendia

Adult dose

Dose: 10 mg once daily initially (eGFR 25-59); increase to 20 mg once daily after 4 weeks if K+ <5.0 mmol/L

Route: Oral

Frequency: Once daily

Max: 20 mg/day

Non-steroidal selective mineralocorticoid receptor antagonist (ns-MRA). FIDELIO-DKD and FIGARO-DKD trials. For diabetic kidney disease. No anti-androgenic effects — no gynaecomastia or sexual dysfunction unlike spironolactone/eplerenone.

Paediatric dose

Route: Oral

Seek specialist opinion — not licensed in children

Dose adjustments

Renal

Start at 10 mg OD if eGFR 25-59. Avoid initiation if eGFR <25. Monitor potassium closely — hyperK risk increases with decreasing eGFR.

Hepatic

Contraindicated in severe hepatic impairment (Child-Pugh C); caution in moderate impairment

Clinical pearls

FIDELIO-DKD (Bakris et al. NEJM 2020): finerenone vs placebo in CKD + T2DM on max ACEi/ARB — 18% relative risk reduction in CKD progression + 14% CV composite reduction
FIGARO-DKD (Pitt et al. NEJM 2021): complementary trial with wider eGFR range — 13% CV event reduction; confirmed benefit across broader CKD spectrum
FIDELITY pooled analysis: 23% renal composite reduction + 14% CV composite reduction across both trials
Key distinction from spironolactone/eplerenone: NON-steroidal MRA — high MR selectivity, no cross-reactivity with androgen/progesterone receptors = no gynaecomastia, erectile dysfunction, or menstrual irregularity
Potassium monitoring protocol: K+ and eGFR at baseline, at 4 weeks (dose uptitration decision based on K+), then every 4 months

Contraindications

Addison's disease
Concomitant strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir)
Potassium >5.0 mmol/L at initiation
eGFR <25 mL/min
Severe hepatic impairment
Pregnancy

Side effects

Hyperkalaemia (most important)
Hypotension
Hyponatraemia
Unlike steroidal MRAs: NO gynaecomastia, NO menstrual irregularity

Interactions

Strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir, clarithromycin) — CONTRAINDICATED (markedly increased finerenone exposure)
Moderate CYP3A4 inhibitors (fluconazole, erythromycin, verapamil) — reduce dose or avoid
Other potassium-raising agents (ACEi, ARB, potassium supplements) — hyperK risk
Grapefruit juice — avoid (CYP3A4 inhibition)

Monitoring

Potassium at baseline, 4 weeks, then every 4 months
eGFR
Blood pressure
Urinary albumin:creatinine ratio

Reference: BNFc; BNF 90; FIDELIO-DKD (Bakris et al. NEJM 2020); FIGARO-DKD (Pitt et al. NEJM 2021); FIDELITY Analysis; NICE TA877; SPC Kerendia. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Drugs

Pathways