Which aldosterone antagonist? Choosing between sprionolactone and the novel drug finerenone
Abstract
Background: Patients with chronic kidney disease (CKD) and metabolic diseases including type 2 diabetes mellitus (T2DM) have an increased cardiovascular risk. Mineralocorticoid receptor overactivation plays a key role in inflammation and fibrosis in heart and kidneys.
Objective: To review the clinical evidence and provide practical guidance on selecting mineralocorticoid receptor antagonists (MRAs) in cardiovascular-kidney-metabolic syndrome.
Discussion: Finerenone reduced kidney and cardiovascular events in patients with T2DM (FIDELIO-DKD, FIGARO-DKD). The CONFIDENCE trial showed reduction of proteinuria when combining finerenone with empagliflozin. Outcome studies are lacking for spironolactone and eplerenone. In heart failure with preserved ejection fraction (HFpEF), FINEARTS-HF demonstrated cardiovascular benefits with finerenone, while TOPCAT with spironolactone showed mixed results. In the Netherlands, finerenone uptake remains limited despite regulatory approval.
Conclusion: Finerenone offers proven efficacy in CKD and DM2. For treatment-resistant hypertension, classic steroidal MRA's remain valuable. Patient-specific factors including blood pressure and susceptibility to hyperkalemia can further guide MRA selection.
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