Non-Steroidal Mineralocorticoid Receptor Antagonist (Diabetic CKD) Pregnancy: Avoid — limited human data. Animal studies show foetal harm. Effective contraception required during treatment.

Finerenone

Brand names: Kerendia

Adult dose

Dose: 10 mg once daily (eGFR 25–60 mL/min); 20 mg once daily (eGFR ≥60 mL/min). Titrate to 20 mg after 4 weeks if potassium ≤4.8 mmol/L

Route: Oral

Frequency: Once daily with or without food

Max: 20 mg/day

Type 2 diabetes with CKD (eGFR ≥25 mL/min, urine ACR ≥30 mg/mmol or ≥300 mg/g, serum potassium ≤5.0 mmol/L). Initial dose based on eGFR. Titrate up at 4 weeks if potassium ≤4.8 mmol/L. Do not initiate if serum potassium >5.0 mmol/L. Source: BNF 90; MHRA SPC Kerendia.

Paediatric dose

Dose: Not licensed under 18 years N/A/kg

Route: N/A

Frequency: N/A

Max: N/A

Not licensed in paediatric diabetic CKD.

Dose adjustments

Renal

eGFR ≥60: start 20 mg. eGFR 25–59: start 10 mg and titrate to 20 mg if tolerated. eGFR <25: not recommended — insufficient data.

Hepatic

Severe hepatic impairment (Child-Pugh C): avoid — significantly increased exposure. Mild-moderate: no dose adjustment required.

Paediatric weight-based calculator

Patient weight (kg)

Not licensed in paediatric diabetic CKD.

Clinical pearls

FIDELIO-DKD trial (NEJM 2020): finerenone reduced composite of kidney failure, ≥40% sustained eGFR decline, or renal death by 18% vs placebo (HR 0.82) in T2DM CKD. FIGARO-DKD: reduced CV events. FIDELITY combined analysis confirmed cardiorenal benefit across spectrum of diabetic CKD.
Non-steroidal MRA advantage over spironolactone/eplerenone: finerenone is more selective for mineralocorticoid receptor vs sex hormone receptors → no gynaecomastia, no erectile dysfunction, no menstrual irregularity — previously limiting side effects of spironolactone. Also less potassium retention at CKD doses than spironolactone.
Tissue selectivity: finerenone has higher selectivity for myocardial and renal MR vs epithelial MR (kidney collecting duct). This may explain the cardiorenal benefit extending beyond the blood pressure and natriuretic effects of older steroidal MRAs.
Fourth pillar of diabetic CKD treatment: evidence now supports FOUR cardioprotective drug classes in diabetic CKD — ACEi/ARB (since IDNT/RENAAL 2001), SGLT2 inhibitor (DAPA-CKD, EMPA-KIDNEY), finerenone (FIDELIO-DKD), plus GLP-1 receptor agonist (FLOW trial NEJM 2024 — semaglutide in CKD). Combination of all four is an emerging standard in high-risk patients.
Do not initiate if K+ >5.0 mmol/L: pre-treatment potassium is the key gate. If potassium is 4.8–5.0, start 10 mg and recheck at 4 weeks. If potassium rises to >5.5 mmol/L during treatment — withhold and reassess diet and concurrent medications. Source: BNF 90; Bakris et al. NEJM 2020 (FIDELIO-DKD); Filippatos et al. NEJM 2021 (FIGARO-DKD).

Contraindications

Serum potassium >5.0 mmol/L at initiation
Concurrent strong CYP3A4 inhibitors (e.g. itraconazole, ketoconazole, clarithromycin, ritonavir) — dramatically increase finerenone levels
Adrenal insufficiency (primary — Addison's disease)
Severe hepatic impairment (Child-Pugh C)
Concurrent potassium-sparing diuretics (spironolactone, eplerenone, amiloride) — dual MRA combination

Side effects

Hyperkalaemia (most important — most common reason for dose reduction/discontinuation; monitor potassium at 4 weeks and 3 months)
Hypotension (especially on initiation — particularly in volume-depleted patients)
Hyponatraemia (rare — MRA sodium-retaining effects at high doses)
No gynaecomastia (non-steroidal selectivity advantage vs spironolactone — does not bind sex hormone receptors)

Interactions

Strong CYP3A4 inhibitors (itraconazole, clarithromycin, ritonavir): contraindicated — increase finerenone AUC 5–17 fold
Moderate CYP3A4 inhibitors (fluconazole, erythromycin, diltiazem): increase finerenone — monitor potassium and consider dose reduction
Strong CYP3A4 inducers (rifampicin, carbamazepine): reduce finerenone exposure — avoid
ACEi, ARBs, SGLT2 inhibitors: may be combined (used in FIDELITY combined analysis) — synergistic cardiorenal protection; monitor potassium
Potassium supplements, potassium-sparing diuretics: additive hyperkalaemia — contraindicated

Monitoring

Serum potassium: at initiation, 4 weeks, then every 3 months
eGFR at baseline and periodically
Blood pressure
Urine ACR (disease activity monitoring every 6 months)
Symptoms of hyperkalaemia (muscle weakness, palpitations) at each visit

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

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways