How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?

Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has failed spironolactone or eplerenone. I will try to prescribe finerenone first if the patient has a baseline K>4.8.

Finerone is a non-steroidal MRA. As such, it has a lower incidence of hyperkalemia than does spironolactone. This is more important when patients have SGLT2I’s used, as they help eliminate potassium in the urine, mitigating any increase in potassium blood levels.

Both finerenone and spironolactone reduce proteinuria and there have been no comparative studies to see which drug reduces it more. However, due to the reduced risk of hyperkalemia seen with finerenone, that is my preferred drug to be u...