Effect of AZD9977 and spironolactone on serum potassium in heart failure with preserved or mildly reduced ejection fraction, and renal impairment: A randomized trial

Non-Steroidal Mineralocorticoid Receptor Antagonists: A Paradigm Shift in the Management of Diabetic Nephropathy

BACKGROUND

Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease worldwide. The management of DKD relies on controlling glycemia and blood pressure levels, as well as reducing proteinuria. While the traditional renin-angiotensin-aldosterone system inhibitors (RAASi) and the recently approved type 2 Na+/glucose co-transporter inhibitors (SGLT2i) have significantly improved patient outcomes, residual risks remain unaddressed.

SUMMARY

This review explores (1) the mechanisms of action of finerenone, a novel non-steroidal mineralocorticoid receptor antagonist (ns-MRA), (2) the evidence of finerenone-induced kidney protection in clinical trials, and (3) the comparative advantages over conventional MRAs. The potential synergy between finerenone and SGLT2i is also addressed, alongside research perspectives and practical considerations for implementation in clinical practice.

KEY MESSAGES

Finerenone has emerged as a breakthrough therapy in the management of DKD, demonstrating robust nephro- and cardio-protective effects.

Concentration-QT modeling demonstrates that the selective mineralocorticoid receptor modulator, balcinrenone (AZD9977), does not prolong QT interval

Balcinrenone (AZD9977) is a selective mineralocorticoid receptor modulator in development in combination with dapagliflozin for treatment of heart failure with impaired kidney function and chronic kidney disease. A prespecified concentration-QT analysis was performed based on data from a phase I single ascending dose study prospectively designed as a thorough QT study substitute. Oral single doses of balcinrenone of 5-800 mg, plus fractionated doses of 800 and 1200 mg, were evaluated in 62 healthy male participants. Time-matched 12-lead digital electrocardiogram and plasma concentrations were measured pre-dose and up to 48 h postdose in the participants. Analysis was performed using a linear mixed-effect model, where baseline-adjusted Fridericia-corrected QT interval (ΔQTcF) was a dependent variable and time-matched balcinrenone concentration an independent variable. The model fit was deemed adequate by evaluation of goodness-of-fit plots, and the slope of the concentration-ΔQTcF relationship was nonsignificant (-0.003 ms/μmol/L; 95% confidence interval [CI]: -0.181, 0.176). The high clinical exposure scenario was defined as the maximum concentration (2.156 μmol/L) following the highest expected therapeutic dose (40 mg once daily) under fed conditions and in presence of a strong cytochrome P450 3A4 inhibitor. Estimated baseline-adjusted and placebo-corrected QTcF interval (ΔΔQTcF) at this concentration was 0.35 ms (90% CI: -1.29, 2.00). Furthermore, the upper 90% ΔΔQTcF CI was estimated to be below the threshold of regulatory concern of 10 ms at all observed concentrations (up to 16.7 μmol/L). Hence, it can be concluded that balcinrenone does not induce QTcF prolongation at the high clinical exposure scenario.

Aldosterone and aldosterone synthase inhibitors in cardiorenal disease

Modulation of the renin-angiotensin-aldosterone system is a foundation of therapy for cardiovascular and kidney diseases. Excess aldosterone plays an important role in cardiovascular disease, contributing to inflammation, fibrosis, and dysfunction in the heart, kidneys, and vasculature through both genomic and mineralocorticoid receptor (MR)-mediated as well as nongenomic mechanisms. MR antagonists have been a key therapy for attenuating the pathologic effects of aldosterone but are associated with some side effects and may not always adequately attenuate the nongenomic effects of aldosterone. Aldosterone is primarily synthesized by the CYP11B2 aldosterone synthase enzyme, which is very similar in structure to other enzymes involved in steroid biosynthesis including CYP11B1, a key enzyme involved in glucocorticoid production. Lack of specificity for CYP11B2, off-target effects on the hypothalamic-pituitary-adrenal axis, and counterproductive increased levels of bioactive steroid intermediates such as 11-deoxycorticosterone have posed challenges in the development of early aldosterone synthase inhibitors such as osilodrostat. In early-phase clinical trials, newer aldosterone synthase inhibitors demonstrated promise in lowering blood pressure in patients with treatment-resistant and uncontrolled hypertension. It is therefore plausible that these agents offer protection in other disease states including heart failure or chronic kidney disease. Further clinical evaluation will be needed to clarify the role of aldosterone synthase inhibitors, a promising class of agents that represent a potentially major therapeutic advance.

Molecular pharmacology of mineralocorticoid receptor antagonists: The role of co-regulators

Mineralocorticoid receptor (MR) antagonists have shown remarkable benefits in the treatment of cardiovascular disease. However, their underutilization in clinical practice may be attributed to concerns regarding the risk of hyperkalemia. An ideal selective MR modulator would inhibit the detrimental effects of MR in non-epithelial cells of the cardiovascular system while sparing its physiological function in kidney epithelial cells, thereby reducing the risk of adverse events. To address this issue, a new generation of non-steroidal MR antagonists, including esaxereneone, balcinrenone, ocedurenone, and finerenone, has been developed with distinct molecular structures and pharmacology. They share a mechanism of action that is different from the previously developed steroidal MR antagonists, leading to altered co-regulator interaction, potentially involving conformational changes of the receptor. Interfering with MR co-regulator interaction or the co-regulator itself may enable selective targeting of downstream signaling cascades and - in the long term - lead to more personalized medicine. In this review article, we summarize what is currently known about the mechanisms of action of the different MR antagonists with a focus on MR co-factor interaction and what may be inferred from this for future developments.

Mineralocorticoid receptor antagonist use in chronic kidney disease with type 2 diabetes: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA)

Chronic kidney disease (CKD) in individuals with type 2 diabetes (T2D) represents a major public health issue; it develops in about 30%-40% of patients with diabetes mellitus and is the most common cause of CKD worldwide. Patients with CKD and T2D are at high risk of both developing kidney failure and of cardiovascular events. Renin-angiotensin system (RAS) blockers were considered the cornerstone of treatment of albuminuric CKD in T2D for more than 20 years. However, the residual risk of progression to more advanced CKD stages under RAS blockade remains high, while in major studies with these agents in patients with CKD and T2D no significant reductions in cardiovascular events and mortality were evident. Steroidal mineralocorticoid receptor antagonists (MRAs) are known to reduce albuminuria in individuals on RAS monotherapy, but their wide clinical use has been curtailed by the significant risk of hyperkalemia and absence of trials with hard renal outcomes. In recent years, non-steroidal MRAs have received increasing interest due to their better pharmacologic profile. Finerenone, the first compound of this class, was shown to effectively reduce the progression of kidney disease and of cardiovascular outcomes in participants with T2D in phase 3 trials. This clinical practice document prepared from a task force of the European Renal Best Practice board summarizes current knowledge on the role of MRAs in the treatment of CKD in T2D aiming to support clinicians in decision-making and everyday management of patients with this condition.