Switching from Spironolactone to Finerenone

Patient Selection and Monitoring

The American College of Cardiology recommends discontinuing spironolactone immediately and checking potassium and creatinine within 2-3 days before initiating finerenone, if potassium is ≤5.0 mEq/L and eGFR >25 mL/min/1.73 m² 1
The American College of Cardiology suggests confirming eGFR is >25 mL/min/1.73 m², and not just serum creatinine, as this underestimates dysfunction in elderly or low muscle mass patients 1
The European Society of Cardiology guidelines support the monitoring protocol established for mineralocorticoid receptor antagonists in heart failure, which includes rechecking potassium and renal function at 3 days, 1 week, then monthly for the first 3 months after starting finerenone 1, 2

The American College of Cardiology recommends starting finerenone at a reduced dose in patients with eGFR 25-60 mL/min/1.73 m² 1
The American College of Cardiology advises against combining ACE inhibitor + ARB + mineralocorticoid receptor antagonist, including finerenone, as this triples hyperkalemia risk 1

The American College of Cardiology notes that concomitant ACE inhibitor or ARB use dramatically increases hyperkalemia risk to 24-36% in real-world practice versus 2-5% in trials 1
The European Society of Cardiology guidelines highlight that baseline potassium >4.0 mEq/L increases hyperkalemia risk 2.65-fold, and chronic kidney disease increases risk 2.47-fold, with progressive risk when creatinine >1.6 mg/dL 1