Chinese Expert Consensus on the Clinical Application of Finerenone in Geriatric Comorbidities (2026 English Version)PubMed

Journal: Aging Medicine (Milton), 2026 Aug 20; DOI: 10.1002/agm2.70103 ｜PMID 42625909 Issuing body: Geriatrics Branch, Chinese Medical Association; Cardiovascular‑Geriatrics‑Group, Geriatrics Branch, Chinese Medical Association Authors: Wang Xiaoming, Zhang Cuntai et al. Original Chinese source: 《非奈利酮在老年疾病临床应用的中国专家共识（2025 版）》, official‑released English translation published 2026

Abstract

Dysregulation of the renin‑angiotensin‑aldosterone system (RAAS) is a key driver for multimorbid‑geriatric‑disorders including cardiovascular‑disease, type‑2‑diabetes‑mellitus (T2DM) and chronic‑kidney‑disease (CKD), and strongly‑correlates‑with‑adverse‑cardiorenal‑end‑points‑in‑older‑adults. Excessive‑mineralocorticoid‑receptor (MR)‑activation‑triggers‑tissue‑inflammation, fibrosis‑and‑oxidative‑stress‑across‑organs, representing‑a‑core‑pathogenic‑mechanism‑of‑cardiorenal‑metabolic‑diseases. As‑a‑selective‑non‑steroidal‑mineralocorticoid‑receptor‑antagonist (ns‑MRA), finerenone‑blocks‑MR‑over‑activation‑without‑classic‑steroid‑related‑side‑effects. Pooled‑phase‑III‑data‑demonstrate‑that‑finerenone‑reduces‑proteinuria, slows‑renal‑function‑decline, and‑lowers‑heart‑failure‑hospitalization‑risk‑in‑elderly‑multimorbid‑patients. This‑consensus‑provides‑practical‑clinical‑algorithms‑for‑finerenone‑initiation, dose‑titration, safety‑monitoring‑and‑comorbidity‑management‑for‑older‑adults‑(≥65 years‑old), including‑frail‑elderly‑populations, and‑addresses‑hyperkalaemia‑risk‑mitigation‑and‑polypharmacy‑issues‑in‑real‑world‑geriatric‑practicePubMed.

Keywords: Finerenone; geriatric‑comorbidities; older‑adults; non‑steroidal‑mineralocorticoid‑receptor‑antagonist; CKD; type‑2‑diabetes‑mellitus; hyperkalaemia

1. Background & Core‑Principles

Older‑adults (≥65 y, especially ≥75 y) frequently‑present‑multimorbidity: CKD, T2DM, ASCVD, heart‑failure (HF), sodium‑sensitivity‑hypertension‑co‑exist‑with‑frailty, malnutrition‑and‑polypharmacy. Elderly‑patients‑have‑higher‑intrinsic‑risk‑of‑hyperkalaemia‑and‑acute‑kidney‑injury‑(AKI). This‑consensus‑adopts‑individualised‑risk‑benefit‑assessment, not‑chronological‑age‑alone. Key‑goals: reduce‑cardiorenal‑events; avoid‑preventable‑adverse‑events; balance‑benefits‑versus‑burden‑of‑monitoring‑in‑frail‑subjects.

Key‑note: Finerenone does not lower blood‑glucose; it‑is‑a‑cardiorenal‑protective‑agent‑independent‑of‑glycaemic‑control.

2. Population‑Selection & Indications

2.1 Prioritised‑population (strong‑conditional‑recommendation)

1. Older‑adults ≥65 y with T2DM‑associated‑CKD: UACR ≥ 30 mg/g (≥3.4 mg/mmol); eGFR ≥ 25 mL/min/1.73 m². 2. Elderly‑patients with CKD‑and‑concomitant‑heart‑failure (HFmrEF/HFpEF/HFrEF), regardless‑of‑diabetes‑status, when‑UACR‑elevated. 3. Elderly‑patients‑with‑ASCVD‑plus‑albuminuric‑CKD‑despite‑optimised‑RAAS‑blockade (ACE‑I/ARB).

2.2 Conditionally‑consider‑(weak‑recommendation, shared‑decision‑making‑required)

1. Salt‑sensitive‑elderly‑hypertension with‑albuminuria; intolerant‑to‑spironolactone‑due‑to‑gynaecomastia, sexual‑dysfunction‑or‑gastrointestinal‑intolerance. 2. Frail‑older‑adults with‑mild‑multimorbidity‑and‑mild‑albuminuria‑only‑after‑careful‑serum‑potassium‑baseline‑evaluation.

2.3 Not‑recommended / contra‑indications

1. Severe‑hepatic‑impairment (Child‑Pugh C). 2. Baseline‑serum‑potassium > 5.5 mmol/L prior‑to‑initiation. 3. End‑stage‑renal‑disease (ESRD) receiving‑dialysis. 4. Pregnancy‑and‑breast‑feeding.

3. Initiation, Dosing‑Strategy

1. Starting‑dose: 10 mg oral once‑daily. 2. Titration‑target‑dose: if‑serum‑potassium remains ≤ 4.8 mmol/L and‑eGFR‑stable‑after‑2‑4‑weeks, uptitrate‑to 20 mg once‑daily (target‑dose). 3. Do‑NOT‑initiate‑at‑20 mg‑directly‑in‑elderly‑≥75 y or‑frail‑subjects. 4. No‑age‑based‑automatic‑dose‑reduction; dose‑adjust‑according‑to‑serum‑potassium‑and‑renal‑function‑only.

‼️ Even‑when‑eGFR‑declines‑after‑starting‑therapy, do‑not‑automatically‑discontinue‑finerenone; re‑assess‑volume‑status, potassium‑and‑exclude‑pre‑renal‑AKI‑causes.

4. Safety‑Monitoring‑Workflow (mandatory‑in‑geriatric‑patients)

1. Baseline‑tests‑before‑starting: - Serum‑potassium (K⁺), eGFR, UACR, electrolytes. 2. Follow‑up‑schedule: - Weeks 2‑4 after‑initiation or dose‑increase: repeat‑K⁺ & renal‑function. - Stable‑patients: every 3 months‑routine‑monitoring; frail/multimorbid‑patients: every 1‑2 months. 3. Management‑of‑elevated‑serum‑potassium‑during‑treatment: - K⁺ 5.1‑5.4 mmol/L: reduce‑dose‑(20 mg→10 mg); review‑dietary‑potassium‑intake; discontinue‑potassium‑rich‑supplements. - K⁺ ≥ 5.5 mmol/L: temporarily‑hold‑finerenone; implement‑potassium‑lowering‑measures (potassium‑binders‑if‑clinically‑indicated); restart‑only‑when‑K⁺ returns‑≤ 5.0 mmol/L‑at‑lower‑dose‑level.

5. Comorbidity‑Specific‑Recommendations

5.1 Elderly‑Heart‑Failure

- For HFpEF/HFmrEF older‑adults with‑albuminuria‑CKD: recommend‑finerenone‑on‑top‑of‑standard‑HF‑therapy (SGLT‑2i‑first‑line‑remains‑unchanged). Finerenone‑is‑additive‑rather‑than‑replacement‑for‑SGLT‑2‑inhibitors. - No‑benefit‑proven‑for‑HF‑without‑albuminuria‑or‑CKD‑in‑older‑adults: not‑routinely‑initiated.

5.2 Elderly‑Hypertension

- Only‑use‑when‑co‑existing‑albuminuria‑CKD‑exists. Not‑an‑antihypertensive‑drug‑per‑se. Do‑not‑prescribe‑for‑isolated‑hypertension‑without‑kidney‑involvement.

5.3 Polypharmacy‑&‑drug‑interaction‑considerations

- Concurrent‑RAAS‑inhibitors (ACE‑I / ARB) can‑be‑continued‑at‑optimised‑doses‑(avoid‑max‑excessive‑dual‑RAAS‑blockade). - Avoid‑concurrent‑high‑dose‑potassium‑supplements. - Drugs‑that‑raise‑serum‑potassium‑(trimethoprim, certain‑NSAIDs‑long‑term‑use)‑require‑closer‑K⁺‑surveillance.

6. Frail‑&‑advanced‑old‑age‑patients (≥80 years)

1. Start‑strictly‑from 10 mg‑once‑daily‑without‑early‑uptitration. 2. Strict‑potassium‑monitoring‑every‑2‑weeks‑in‑initial‑phase. 3. If‑life‑expectancy‑is‑limited‑(< 1‑year), weight‑treatment‑burden‑against‑expected‑long‑term‑cardiorenal‑benefits‑through‑shared‑clinical‑decision‑making.

7. Key‑Safety‑Warnings

1. Hyperkalaemia‑is‑the‑major‑clinically‑relevant‑adverse‑event; gynaecomastia‑and‑sex‑hormone‑disturbance‑rates‑are‑very‑low‑compared‑with‑steroidal‑MR‑antagonists‑(spironolactone). 2. Mild‑transient‑eGFR‑drop‑is‑common‑shortly‑after‑initiation‑due‑to‑haemodynamic‑effects; usually‑does‑not‑represent‑permanent‑renal‑damage. 3. Finerenone‑is‑not‑indicated‑for‑acute‑kidney‑injury‑episodes‑during‑acute‑illness‑(infection, dehydration, sepsis); temporary‑hold‑during‑acute‑stress‑periods.

8. Consensus‑Summary‑Recommendations (Take‑home‑statements)

1. Finerenone‑provides‑cardiorenal‑protection‑for‑selected‑multimorbid‑older‑adults‑with‑albuminuric‑CKD‑(predominantly‑T2DM‑related), independent‑of‑glycaemic‑control. 2. Age‑≥65 or‑≥75 alone‑is‑not‑a‑contraindication; frailty, baseline‑potassium‑and‑eGFR‑are‑more‑important‑than‑chronological‑age. 3. Mandatory‑baseline‑K⁺ &‑renal‑function; close‑early‑potassium‑surveillance‑after‑initiation‑or‑dose‑increase. 4. Starting‑dose 10 mg daily; uptitrate‑to‑20 mg‑only‑if‑potassium‑remains‑well‑controlled. 5. SGLT‑2‑inhibitors‑remain‑first‑line‑cardiorenal‑therapy‑for‑older‑diabetic‑CKD‑patients; finerenone‑can‑be‑added‑on‑top‑when‑UACR‑remains‑elevated‑despite‑SGLT‑2‑inhibitor‑therapy. 6. Do‑not‑use‑in‑dialysis‑patients, severe‑liver‑cirrhosis‑or‑pre‑treatment‑hyperkalaemia > 5.5 mmol/L. 7. For‑very‑old‑frail‑subjects‑(≥80 y), shared‑decision‑making‑is‑required‑to‑balance‑long‑term‑benefit‑versus‑monitoring‑burden.

9. Evidence‑Gaps‑mentioned‑in‑consensus

1. Limited‑large‑RCT‑data‑specific‑for‑Chinese‑very‑old‑frail‑geriatric‑populations. 2. Real‑world‑long‑term‑outcome‑data‑in‑non‑diabetic‑CKD‑elderly‑remains‑limited. 3. Optimal‑potassium‑target‑threshold‑in‑advanced‑frail‑older‑adults‑still‑debated.