Do you start finerenone right away or wait for better glycemic control in a patient with CKD, type 1 diabetes, an HbA1c of 10% or higher, and persistent albuminuria on a maximally tolerated ACE inhibitor or ARB?
In a patient with CKD, type 1 diabetes, an HbA1c of 10% or higher, and persistent albuminuria on a maximally tolerated ACE inhibitor or ARB, when do you start finerenone?
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Good question – this has been looked at (Rossing et al., PMID 42160608), and benefits and safety are independent of A1c. Accordingly, it is reasonable to start finerenone at essentially any level of A1c, unless there is concern that the patient has an osmotic-induced state of volume depletion.
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My clinical approach is usually to address one problem at a time in order to avoid patient confusion and competing priorities. Lowering A1C is clearly standard of care for patients with nephropathy and T1DM (Nathan et al., PMID 8366922). Adults with T1DM and an A1C over 10% either have problems acce...
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Finerenone is metabolically neutral, so it is possible to start it at any time in a person with T1D and albuminuria.
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