As a hospital pharmacist, you will hear about a new medication finerenone (Kerendia) 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 (Aldactone) 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/1.73m², and consider the monthly cost.
Expect finerenone to be saved as a last resort in patients with CKD due to type 2 diabetes. blood pressure (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 medications 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.
REFERENCES
-
Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Kolkhof P, Nowack C, Schloemer P, Joseph A, Filippatos G; FIDELIO-DKD Investigators. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med. 2020 Dec 3;383(23):2219-2229. Available at: https://www.nejm.org/doi/10.1056/NEJMoa2025845
Pitt B, Filippatos G, Agarwal R, Anker SD, Bakris GL, Rossing P, Joseph A, Kolkhof P, Nowack C, Schloemer P, Ruilope LM; FIGARO-DKD Investigators. Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes. N Engl J Med. 2021 Dec 9;385(24):2252-2263. Available at: https://www.nejm.org/doi/10.1056/NEJMoa2110956
American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S151-S167. Available at: https://diabetesjournals.org/care/article/44/Supplement_1/S151/30492/11-Microvascular-Complications-and-Foot-Care