Effectiveness of nonsteroidal mineralocorticoid receptor antagonists in patients with diabetic kidney disease

Authors

Edgar Lerma, Advocate Aurora Health
William B. White, Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA.
George Bakris, American Heart Association Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA.

Recommended Citation

Lerma E, White WB, Bakris G. Effectiveness of nonsteroidal mineralocorticoid receptor antagonists in patients with diabetic kidney disease. Postgrad Med. 2023;135(3):224-233. doi:10.1080/00325481.2022.2060598

Affiliations

Advocate Christ Medical Center

Abstract

Nonsteroidal mineralocorticoid receptor antagonists (MRAs) are a new class of drugs developed to address the medical need for effective and safer treatment to protect the kidney and the heart in patients with diabetic kidney disease (DKD). There are several drugs within this class at varying stages of clinical development. Finerenone is the first nonsteroidal MRA approved in the US for treating patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). In clinical studies, finerenone slowed CKD progression without inducing marked antihypertensive effects. Esaxerenone is a nonsteroidal MRA with proven blood pressure-lowering efficacy that is currently licensed in Japan for treating hypertension. There are also three other nonsteroidal MRAs in mid-to-late stages of clinical development. Here we overview evidence addressing pharmacological and clinical differences between the nonsteroidal MRAs and the steroidal MRAs spironolactone and eplerenone. First, we describe a framework that highlights the role of aldosterone-mediated pathological overactivation of the mineralocorticoid receptor and inflammation as important drivers of CKD progression. Second, we discuss the benefits and adverse events profile of steroidal MRAs, the latter of which are often a limiting factor to their use in routine clinical practice. Finally, we show that nonsteroidal MRAs differ from steroidal MRAs based on pharmacology and clinical effects, giving the potential to expand the therapeutic options for patients with DKD. In the recently completed DKD outcome program comprising two randomized clinical trials-FIDELIO-DKD and FIGARO-DKD-and the FIDELITY analysis of both trials evaluating more than 13,000 patients, the nonsteroidal MRA finerenone demonstrated beneficial effects on the kidney and the heart across a broad spectrum of patients with CKD and T2D. The long-term efficacy of finerenone on cardiac and renal morbidity and mortality endpoints, along with the anti-hypertensive efficacy of esaxerenone, widens the scope of available therapies for patients with DKD.

Document Type

Article

PubMed ID

35392754