From the Guidelines
Finerenone is the recommended newer alternative diuretic to spironolactone and eplerenone for heart failure that does not cause gynecomastia. It is a non-steroidal, selective mineralocorticoid receptor antagonist (MRA) that was FDA-approved in 2021 1. The typical starting dose is 10 mg once daily for patients with eGFR ≥60 mL/min/1.73 m² and 10 mg every other day for those with lower kidney function. Finerenone works by blocking aldosterone receptors, reducing sodium reabsorption and potassium excretion, but its non-steroidal structure means it doesn't bind to androgen or progesterone receptors, which is why it avoids the gynecomastia side effect seen with spironolactone.
Some key points to consider when prescribing finerenone include:
- Regular monitoring of serum potassium levels is still necessary as hyperkalemia remains a potential side effect 1
- Finerenone has shown benefits in reducing cardiovascular events and slowing kidney disease progression in patients with chronic kidney disease and type 2 diabetes, making it particularly valuable for heart failure patients with these comorbidities
- The use of aldosterone antagonists, such as spironolactone and eplerenone, has been associated with an increased risk of hyperkalemia, particularly in patients with renal dysfunction 1
- Eplerenone is a more selective MR antagonist than spironolactone, but it may not be clinically superior to spironolactone in treating certain conditions 1
Overall, finerenone is a valuable addition to the treatment options for heart failure, offering a non-steroidal alternative to spironolactone and eplerenone that avoids the gynecomastia side effect.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Alternative Diuretic to Spironolactone and Eplerenone
- Finerenone is a novel non-steroidal mineralocorticoid receptor antagonist that has been introduced as a potential alternative to spironolactone and eplerenone for the treatment of heart failure 2, 3.
- Finerenone has been shown to be as potent as spironolactone in improving cardiovascular outcomes, but with fewer adverse effects, including a lower risk of hyperkalemia and gynecomastia 2, 4.
- Studies have demonstrated that finerenone is effective in reducing albuminuria and improving renal function in patients with chronic kidney disease and diabetes, with a lower risk of adverse effects compared to spironolactone and eplerenone 2, 3, 5.
Comparison to Spironolactone and Eplerenone
- Finerenone has a higher selectivity towards the mineralocorticoid receptor compared to spironolactone and eplerenone, which may reduce the risk of hyperkalemia and renal dysfunction 3.
- Finerenone has been shown to be equivalent to spironolactone and eplerenone in terms of anti-ventricular remodeling, but with a lower incidence of treatment-related adverse events 5.
- The efficacy of finerenone appears to be dose-dependent, with a dose of 10mg/d being marginally better than steroidal mineralocorticoid receptor antagonists 5.
Safety and Efficacy
- Finerenone has been shown to be well-tolerated and effective in reducing NT-proBNP levels and improving cardiovascular outcomes in patients with heart failure 4, 5.
- The incidence of treatment-related adverse events, including hyperkalemia and gynecomastia, is lower with finerenone compared to spironolactone and eplerenone 2, 4, 5.
- Finerenone may be a safer option for patients with chronic kidney disease, with a lower risk of adverse renal and cardiac outcomes 2, 3, 5.