Finerenone and ACE Inhibitor Combination Therapy in Chronic Kidney Disease

Safety and Efficacy of the Combination

The American Diabetes Association recommends the combination of finerenone and ACE inhibitors for patients with chronic kidney disease and type 2 diabetes, as it has shown significant benefits in reducing composite endpoints related to progression of renal disease and cardiovascular disease 1, 2
Mineralocorticoid receptor antagonists like finerenone in combination with ACE inhibitors remain an area of clinical interest due to their complementary mechanisms in reducing albuminuria and providing cardiovascular benefits 3, 4

The primary concern with combining finerenone and ACE inhibitors is the increased risk of hyperkalemic episodes, which has been observed in clinical studies 3, 4, 2
In the FIDELIO-DKD trial, hyperkalemia occurred in 10.8% of patients on finerenone (who were also on ACE inhibitors or ARBs) compared to 5.3% in the placebo group, though only 1.2% discontinued treatment due to hyperkalemia 1
Risk factors for hyperkalemia include concomitant use of other potassium-sparing medications 5 and higher baseline serum potassium levels 1

Regular monitoring of serum potassium levels is essential when using this combination, particularly within the first month after starting treatment, after any dose adjustments, and periodically during continued therapy 1, 2

Starting with lower doses of finerenone (10 mg daily) is recommended for patients with eGFR 25-60 mL/min/1.73 m² 1
Dose can be increased to 20 mg daily after one month if serum potassium is ≤4.8 mmol/L and eGFR remains stable 1

The combination of ACE inhibitors with ARBs should be avoided due to increased risk of adverse events (hyperkalemia and/or acute kidney injury) without additional benefits 3, 4, 1, 5
Use with caution in patients with advanced kidney disease (eGFR <30 mL/min/1.73 m²) 1, history of hyperkalemia 5, and concomitant use of other potassium-sparing medications 1, 5

Switching from ACE inhibitor to calcium channel blocker if appropriate for the patient's condition may be considered if hyperkalemia becomes a persistent issue 6