Written by Babatunde Carew
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Finerenone significantly reduces the risk of CKD progression and cardiovascular events in patients with type 2 diabetes.
Finerenone puts a fin-ish to renal decline?
Diabetes is the leading cause of chronic kidney disease (CKD). Along with glucose and blood pressure control, American Diabetes Association (ADA) guidelines recommend an ACEi/ARB and SGLT2i to slow CKD progression. As of January 2024, the ADA recommends considering a GLP1a or nonsteroidal mineralocorticoid receptor antagonist (MRA) to reduce the risk of CKD progression and cardiovascular events, likely influenced by this study, FIDELIO-DKD.
This double-blind randomized trial (n=5,734) found that finerenone significantly reduced the primary composite outcome of kidney failure, ≥40% eGFR decline, or death from renal cause, with a hazard ratio (HR) of 0.82 (95%CI 0.73–0.93, p=0.001). The secondary composite outcome, death from cardiovascular cause, nonfatal MI, nonfatal stroke, or hospitalization for heart failure, also improved (HR 0.86, 0.75–0.99, p=0.03).
The study focused on patients with advanced CKD and excluded those with non-albuminuric CKD or CKD not caused by type 2 diabetes, which limits generalizability. It was also industry-funded by Bayer.
How does this change my practice?
I will consider starting finerenone in select patients with T2DM and CKD already on maximally tolerated ACEi/ARB and SGLT2i therapy, or those unable to take an SGLT2i, while watching for hyperkalemia. In similar patients with coexisting obesity, however, I will prioritize a GLP1a. At around $700 on GoodRx, cost is a barrier to finerenone use. Interestingly, while all patients in the study were on maximally tolerated ACEi/ARB therapy, only 4.6% received an SGLT2i and 6.9% a GLP1a. I would like to see future studies evaluating finerenone benefits in similar populations taking ACEi/ARB concurrent with an SGLT2i or GLP1a.
Source
Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med. 2020 Dec 3;383(23):2219-2229. doi: 10.1056/NEJMoa2025845. Epub 2020 Oct 23. PMID: 33264825
