From the Guidelines
Finerenone is beneficial for patients with heart failure, particularly those with chronic kidney disease and type 2 diabetes, as it reduces the risk of cardiovascular events and slows kidney disease progression, as shown in the most recent study 1. The recommended starting dose is 10 mg once daily for patients with eGFR ≥60 mL/min/1.73m², and 10 mg every other day for those with eGFR 25-60 mL/min/1.73m². Key points to consider when prescribing finerenone include:
- The dose can be increased to 20 mg daily after 4 weeks if serum potassium remains ≤4.8 mmol/L and renal function is stable.
- Finerenone works as a non-steroidal, selective mineralocorticoid receptor antagonist that reduces inflammation and fibrosis in the heart and kidneys.
- It has been shown to reduce cardiovascular events, including a 13% reduction in the primary composite outcome of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure, as demonstrated in the FIGARO-DKD trial 1.
- Regular monitoring of potassium levels is essential, particularly within the first 4 weeks of treatment and after dose increases, due to the increased risk of hyperkalemia, as noted in the study 1.
- Finerenone should be used cautiously with other medications that increase potassium levels and is contraindicated in patients with adrenal insufficiency or severe hepatic impairment.
- It complements other heart failure therapies like ACE inhibitors, ARBs, beta-blockers, and SGLT2 inhibitors, offering additional cardiorenal protection through its unique mechanism of action, as discussed in the study 1.
From the Research
Finerenone and Heart Failure
- Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist that has shown promising results in the treatment of heart failure and diabetic kidney disease 2.
- Studies have demonstrated that finerenone reduces the risk of hospitalizations and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4.
- Finerenone has been associated with a 20% reduction in HF hospitalization risk and a 14% reduction in all-cause mortality 3.
- The selectivity and greater binding affinity of finerenone to the mineralocorticoid receptor may reduce the risk of hyperkalemia and renal dysfunction, making it a potential treatment option for patients with HF and diabetic kidney disease 2, 5.
Mechanism of Action
- Finerenone antagonizes the mineralocorticoid receptor, decreasing the amount of fibrosis and inflammation observed in many heart failure patients 4.
- Finerenone exhibits a reduction in the incidence of cardiovascular outcomes among patients with chronic kidney disease and type 2 diabetes mellitus 4, 6.
Safety and Efficacy
- Finerenone has been shown to have a better renal outcome compared to spironolactone and a better mortality outcome compared to eplerenone, with significantly lesser hyperkalemia compared to both spironolactone and eplerenone 5.
- However, hyperkalemia leading to drug withdrawal was significantly higher with finerenone compared to placebo 5.
- Finerenone has no effect on HbA1c, body weight, and sexual side effects including gynecomastia, and has only a modest effect on blood pressure 5.
Future Directions
- Further studies are needed to clarify the effects of finerenone on cardiovascular death and renal failure 3, 4.
- Ongoing trials are investigating the use of finerenone in dedicated heart failure patients to prove its worth in this sector with huge unmet need despite guideline-directed medical therapy (GDMT) 6.