skip to main content

CKD associated with type 2 diabetes treated with finerenone; uncomplicated lower urinary tract infection — MSR

Instant feedback + full explanation. One question, done properly.

HardNephrologyCKD associated with type 2 diabetes treated with finerenone; uncomplicated lower urinary tract infectionMSRA

A 68-year-old woman with type 2 diabetes and CKD G3a A3 is reviewed urgently for dysuria, urinary frequency and suprapubic discomfort for 24 hours. She has no fever, rigors, flank pain, vomiting or vaginal symptoms. She is clinically euvolaemic, temperature is 36.7°C and BP is 128/74 mmHg. Urine dipstick is positive for nitrites and leucocytes. Her eGFR is stable at 54 mL/min/1.73 m² and potassium is 4.8 mmol/L. She takes ramipril 10 mg once daily, dapagliflozin 10 mg once daily and finerenone 10 mg once daily. Finerenone was started 6 weeks ago after optimisation of ACE inhibitor and SGLT2 inhibitor treatment. A previous urine culture grew Escherichia coli susceptible to nitrofurantoin and trimethoprim. She has not received antibiotics in the past 3 months and has no drug allergies. What is the most appropriate immediate oral antimicrobial management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Prescribe nitrofurantoin modified-release 100 mg twice daily for 3 days while continuing finerenone

This is an uncomplicated lower UTI: she has typical lower urinary symptoms with supportive dipstick findings, without features of pyelonephritis, sepsis or an alternative gynaecological diagnosis. Nitrofurantoin is a NICE first-choice option for non-pregnant women with lower UTI when eGFR is at least 45 mL/minute; her eGFR is 54 mL/min/1.73 m². It also avoids an unnecessary interaction with finerenone. Trimethoprim is otherwise a plausible first-line option because there is no recent exposure and previous susceptibility is known. However, finerenone prescribing information identifies trimethoprim (including co-trimoxazole) as increasing hyperkalaemia risk; potassium monitoring is required and temporary interruption of finerenone may be necessary. In a patient already taking ramipril, with CKD and potassium near the upper end of normal, nitrofurantoin is the safer guideline-concordant first choice. Amoxicillin should not be used empirically unless culture confirms susceptibility. Pivmecillinam and fosfomycin are reasonable alternatives when first-line agents are unsuitable, but neither is preferred here because nitrofurantoin is suitable, supported by prior susceptibility and avoids avoidable disruption to renoprotective treatment.

Reference: Urinary tract infection (lower): antimicrobial prescribing — Recommendations (2018; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng109/chapter/Recommendations Kerendia 10 mg film-coated tablets — Summary of Product Characteristics (2026; checked 16 August 2026) — https://www.medicines.org.uk/emc/product/13437/smpc Finerenone for treating chronic kidney disease in type 2 diabetes — Recommendations (2023; updated September 2024) — https://www.nice.org.uk/guidance/TA877/chapter/1-recommendations