Finerenone

KERENDIA

What it isNon-steroidal mineralocorticoid receptor antagonist; diabetic kidney disease.

Why this oneCardiovascular and renal outcome benefit without the gynecomastia of spironolactone, because it is non-steroidal.

What limits itHyperkalemia is the limiting toxicity and needs a potassium check before and during. CYP3A4-dependent.

FDA-approved for

FDA dosing	Population	Start	Target	Max
CKD associated with T2DM	adult	10–20 mg QD (by eGFR)	20 mg QD	20 mg QD
Heart failure with LVEF ≥40%	adult	10–20 mg QD (by eGFR)	20–40 mg QD	40 mg QD

Titration Up-titrate after 4 weeks based on serum potassium and eGFR.

Renal eGFR ≥60: start 20 mg QD; eGFR 25 to <60: start 10 mg QD; eGFR <25: initiation not recommended.

Hepatic Undefined

Take with or without food.
May crush and mix with water or soft food (e.g., applesauce) if unable to swallow whole.
Measure serum potassium and eGFR before initiation; do not start if potassium >5.0 mEq/L.
Measure serum potassium 4 weeks after initiation/adjustment and periodically.

Hyperkalemia (greater with decreased kidney function/higher baseline potassium) — monitor
Worsening of renal function in patients with heart failure

Pregnancy No human data; animal developmental toxicity at ~2x expected human exposure.

Lactation No data; avoid breastfeeding during treatment and for 1 day after.

NO BOXED WARNINGS

Principal riskHyperkalemia

Cost, est. cash$300–$2,500/month

Generic entry2035 est.

Therapeutic safety burden2 / 4

Overdose danger3 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk2 / 4

Legacy pregnancy categoryNot assigned — PLLR-era drug

Defining liabilityHyperkalemia and kidney dysfunction, especially with RAAS blockers or impaired renal function.

CYP3A4 substrate