Does Finerenone Have Antihypertensive Action?
Yes, finerenone does have modest antihypertensive activity, reducing systolic blood pressure by approximately 2–3 mm Hg, but this blood pressure reduction accounts for only 12–14% of its overall cardiorenal benefit—the drug's primary value lies in its direct kidney and cardiovascular protection, not blood pressure control. 1
Blood Pressure–Lowering Effect
- Finerenone reduces office systolic blood pressure across all baseline blood pressure quartiles in patients with type 2 diabetes and chronic kidney disease, including those with baseline systolic blood pressure >148 mm Hg. 1
- The KDIGO 2022 guideline explicitly labels finerenone with a "blood pressure cuff" icon, indicating recognized blood pressure–lowering activity alongside its kidney and heart protection benefits. 2
- In the FIDELIO-DKD trial, time-varying analysis revealed that only 13.8% of the treatment effect on the primary kidney composite outcome and 12.6% of the cardiovascular outcome were attributable to the change in systolic blood pressure. 1
Mechanism and Clinical Context
- The blood pressure reduction with finerenone is hemodynamic and modest, not the primary therapeutic mechanism—the drug's cardiorenal benefits are predominantly mediated through direct mineralocorticoid receptor antagonism, reducing inflammation, oxidative stress, and fibrosis in kidney and cardiac tissue. 3, 4
- Preclinical studies demonstrate that finerenone improves diastolic dysfunction, reduces cardiac fibrosis, and increases endothelial nitric oxide synthase phosphorylation independently of changes in kidney function or blood pressure, confirming that blood pressure lowering is a secondary, not primary, effect. 4
Practical Implications for Hypertension Management
- Do not prescribe finerenone as a primary antihypertensive agent; ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and diuretics remain first-line therapies for blood pressure control in patients with diabetes and chronic kidney disease. 2
- Finerenone should be added after maximizing RAS inhibition (ACE inhibitor or ARB) and, when appropriate, an SGLT2 inhibitor, specifically for patients with persistent albuminuria (UACR ≥30 mg/g) despite optimal therapy. 2, 5
- The modest blood pressure reduction with finerenone is a beneficial ancillary effect, not a reason to initiate therapy—the drug's indication is cardiorenal protection in type 2 diabetes with chronic kidney disease and albuminuria. 5, 6
Evidence Quality and Strength
- The blood pressure data derive from the FIDELIO-DKD trial (N=5669), a phase 3 randomized controlled trial with robust methodology and time-varying analysis to isolate the blood pressure contribution to outcomes. 1
- Cardiorenal outcomes improved with finerenone irrespective of baseline systolic blood pressure quartiles (P for interaction 0.87 for kidney outcomes and 0.78 for cardiovascular outcomes), confirming that the drug's benefit is not dependent on baseline blood pressure or the magnitude of blood pressure reduction. 1
Common Pitfall to Avoid
- Do not withhold finerenone in patients with well-controlled blood pressure; the drug's kidney and cardiovascular protection are independent of baseline blood pressure, and the modest additional blood pressure lowering (2–3 mm Hg) is safe and does not cause clinically significant hypotension in trial populations. 1