[Which aldosterone antagonist? Choosing between sprionolactone and the novel drug finerenone].

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.