What is the preferred treatment between finerenone and spironolactone (aldosterone antagonist) for patients with heart failure and hypertension?

Finerenone vs. Spironolactone for Heart Failure and Hypertension

Spironolactone is the preferred treatment over finerenone for patients with heart failure and hypertension due to its established efficacy, extensive clinical experience, and strong evidence supporting mortality and morbidity benefits. 1

Comparative Analysis

Spironolactone

• Established efficacy: Spironolactone has demonstrated a 30% reduction in mortality risk in patients with severe heart failure in landmark trials 2
• Guideline recommendations: Strongly recommended in heart failure management guidelines for:
  • NYHA class III-IV heart failure with LVEF ≤35% 1
  • Resistant hypertension as an add-on therapy 1
• Dosing: Typically started at 25 mg daily with target dose of 25-50 mg daily 1
• Cost: Generally more affordable and widely available

Finerenone

• Newer agent: Third-generation nonsteroidal MRA with higher selectivity toward mineralocorticoid receptors 3
• Potential advantages: May have lower risk of hyperkalemia and sexual side effects compared to spironolactone 3
• Evidence base: Less established clinical evidence for heart failure and hypertension compared to spironolactone
• Availability: More limited availability in clinical practice

Decision Algorithm

1. First-line choice: Spironolactone for most patients with heart failure and hypertension

   • Particularly beneficial in:
     • Heart failure with reduced ejection fraction (HFrEF) 1
     • Resistant hypertension 1

2. Consider finerenone instead when:

   • Patient experiences significant endocrine side effects from spironolactone (gynecomastia, breast pain) 1
   • Higher risk of hyperkalemia but requires MRA therapy 3

3. Consider eplerenone when:

   • Sexual side effects occur with spironolactone 1
   • Male patients with breast discomfort or enlargement 1

Implementation Guidelines

For spironolactone:

• Initial assessment: Check renal function and serum electrolytes
• Starting dose: 25 mg once daily
• Monitoring: Recheck renal function and electrolytes at 1 and 4 weeks after initiation
• Titration: Consider dose increase to 50 mg daily after 4-8 weeks if tolerated 1

Monitoring for adverse effects:

• Hyperkalemia: If potassium rises to >5.5 mmol/L, halve dose; if >6.0 mmol/L, stop medication 1
• Renal dysfunction: If creatinine rises to >220 μmol/L (2.5 mg/dL), reduce dose; if >310 μmol/L (3.5 mg/dL), discontinue 1
• Endocrine effects: If gynecomastia develops (occurs in ~10% of men), consider switching to eplerenone or finerenone 1, 3

Special Considerations

• Blood pressure targets: In heart failure patients, SBP target of 110-130 mmHg is recommended 1
• Combination therapy: Spironolactone works well with ACE inhibitors/ARBs, beta-blockers, and diuretics for heart failure 1
• CKD patients: Use with caution; higher risk of hyperkalemia but may still be appropriate with careful monitoring 4

Conclusion

Based on current guidelines and evidence, spironolactone remains the preferred mineralocorticoid receptor antagonist for patients with heart failure and hypertension due to its proven mortality benefit, extensive clinical experience, and guideline recommendations. Finerenone may be considered in specific situations where spironolactone's side effect profile is problematic, but it currently lacks the robust evidence base that supports spironolactone use in this patient population.