Chinese Expert Consensus on Clinical Application of Finerenone in Elderly Patients with Comorbidities (2026)

Original Chinese name：《非奈利酮在老年疾病临床应用的中国专家共识 (2025 版)》，英文版题名常标注为 Chinese Expert Consensus on the Clinical Application of Finerenone in Geriatric Diseases (2025 Edition)；2026 年发布英文版本，中华医学会老年医学分会、老年心血管病学组，Chinese Journal of Geriatrics。 Core positioning: geriatric comorbidity-oriented, MDT consensus for elderly patients with multiple chronic conditions (T2DM, CKD, HF, hypertension), focusing on individualized risk-benefit assessment, hyperkalemia and renal safety, polypharmacy management; compatible with BMJ living guideline of T2DM, SGLT2i/GLP‑1RA heart-kidney protection strategy.

1. Background & Core Concept

Dysregulation of renin‑angiotensin‑aldosterone system (RAAS) and over‑activation of mineralocorticoid receptor (MR) drive inflammation, fibrosis and oxidative stress, contributing to cardiorenal damage in older adults with multiple comorbidities. Finerenone is a non‑steroidal mineralocorticoid receptor antagonist (nsMRA) with selective MR blockade, proven to reduce cardiorenal events in elderly population.

Elderly patients feature multimorbidity, polypharmacy, frailty, malnutrition, higher risk of hyperkalemia and acute kidney injury. This consensus emphasizes comprehensive geriatric assessment (CGA) before initiation, not merely lab threshold.

2. Evidence Base in Elderly Population

• FIDELIO‑DKD: mean age 65.4±8.9 years; efficacy and safety consistent between ≥65y and younger patients; no routine age‑based dose reduction required中华肾脏病....
• FIDELITY post‑hoc analysis: consistent renal and cardiovascular benefit in <65y and 65–74y subgroups; reduces albuminuria and slows eGFR decline.
• FINEARTS‑HF: benefit confirmed in older HFmrEF/HFpEF patients, modest systolic BP reduction.

3. Indications for Elderly Patients

✅ CKD with T2DM (highest priority)

eGFR ≥25 mL/min/1.73m² + albuminuria (UACR ≥30 mg/g). Priority for elderly patients with high risk of CKD progression, ASCVD, heart failure.

✅ Heart failure

• HFrEF combined with CKD: may consider finerenone;
• HFmrEF / HFpEF: early initiation recommended, especially with concomitant CKD or diabetes.

✅ Hypertension

Essential hypertension complicated with diabetic nephropathy, HFmrEF/HFpEF.

NOT indicated for hypertension without albuminuria or heart failure; not for primary left ventricular hypertrophy without albuminuria.

4. Contraindications

1. Severe hyperkalemia at baseline (serum K⁺ >5.0 mmol/L before optimization)
2. Hypersensitivity to finerenone
3. eGFR <25 mL/min/1.73m²
4. Untreated Addison disease

5. Pre‑initiation Assessment (mandatory for elderly)

1. Lab: serum potassium, eGFR, UACR
2. Comprehensive geriatric assessment: frailty, nutritional status, cognitive function, falls risk
3. Medication reconciliation: identify potassium‑raising drugs (ACEi/ARB, trimethoprim, NSAIDs, potassium supplements)
4. Dietary review: high potassium diet, renal diet adherence

Malnourished older adults carry elevated hyperkalemia risk.

6. Dosing & Titration Strategy

• Starting dose: 10 mg once daily
• Target dose: 20 mg once daily, if K⁺ remains <4.8 mmol/L and eGFR stable after 4 weeks
• No automatic dose reduction merely based on age ≥75y, but frailty, low body weight, malnutrition warrant slower titration and tighter monitoring.
• Dose down or pause if K⁺ rises to 5.0–5.4 mmol/L; discontinue if K⁺ ≥5.5 mmol/L.

7. Safety Monitoring (key for geriatric patients)

1. First check: 1 week after initiation or dose up-titration
2. Stable patients: every 4 weeks for the first 3 months; quarterly afterwards
3. Monitoring items: serum potassium, eGFR, blood pressure
4. Education: avoid overuse of potassium supplements, high‑potassium fruits, NSAIDs
5. Warn about AKI risk during dehydration (diarrhea, fever, poor oral intake)

8. Combination Therapy (aligned with prior T2D living guideline)

1. Finerenone + RAASi (ACEi/ARB): foundational combination; optimize RAASi to maximum tolerated dose before adding finerenone.
2. Finerenone + SGLT2i: preferred triple cardiorenal protection (RAASi + SGLT2i + finerenone) in high‑risk DKD; monitor potassium closely.
3. Finerenone + GLP‑1RA/GIP‑GLP‑1 agonist: safe combination for elderly T2DM with obesity; GLP‑1 therapy improves insulin resistance and body composition without interfering potassium.

Do NOT combine with spironolactone/eplerenone.

9. Special Geriatric Subgroups

1. Frail / pre‑frail elderly: individualize benefit‑risk; start low, monitor frequently; avoid if life expectancy limited.
2. Elderly with polypharmacy: clinical pharmacist medication review to reduce potassium‑elevating agents.
3. Elderly with malnutrition: higher hyperkalemia risk; optimize nutrition before treatment.
4. Old‑old ≥80 years: CGA mandatory; reserve for those with clear cardiorenal high risk and good monitoring accessibility.

10. Core Recommendation Principles

1. Finerenone delivers organ protection independent of glucose lowering.
2. In elderly multimorbidity, CGA + potassium/renal monitoring is more important than rigid age cut‑off.
3. Not all elderly T2D/CKD patients need finerenone; only those with albuminuria and acceptable potassium.
4. Multidisciplinary team: geriatrician, nephrologist, cardiologist, clinical pharmacist collaborate.

11. Limitations & Evidence Gaps

1. Limited real‑world long‑term data for adults ≥85 years.
2. Evidence in non‑diabetic CKD remains exploratory.
3. Potassium monitoring access is a practical barrier in primary care.
4. Cost‑effectiveness varies in low‑resource geriatric settings.

12. Cross comparison with previous guideline series

1. This consensus: geriatric multimorbidity, finerenone safety, hyperkalemia management, polypharmacy reconciliation.
2. BMJ living guideline for T2D: SGLT2i, GLP‑1RA, finerenone cardiorenal efficacy stratification.
3. N-RCSP primary nutrition clinic / 2025 Chinese weight management guideline: nutritional intervention for elderly obese patients, malnutrition correction to reduce hyperkalemia risk.
4. SMS 2026 menopause obesity statement: focuses on women’s body composition and 肠促胰岛素；this consensus targets elderly cardiorenal protection.

Disclaimer: This English summary is for academic study only, not for direct clinical prescription. Finerenone requires cardiorenal assessment and close potassium monitoring in elderly comorbid patients.