Aldosterone is a pathologic agent in heart failure and albuminuric chronic kidney disease (CKD); blockade of the renin–angiotensin–aldosterone system is known to reduce morbidity and mortality in these disease states. |
Finerenone is a novel non-steroidal mineralocorticoid receptor antagonist (MRA) that has a unique chemical structure as compared to steroidal MRAs (i.e., spironolactone and eplerenone) with a lower incidence of treatment-related hyperkalemia and acute kidney injury and a smaller effect on systolic blood pressure. |
The FIGARO-DKD and FIDELIO-DKD trials demonstrated that treatment with finerenone in participants with type II diabetes and albuminuric CKD, already on angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker therapy, resulted in improved cardiovascular outcomes and a lower risk of CKD progression. |
Randomized controlled trials are ongoing to assess use in patients with heart failure with preserved ejection fraction (HFpEF) and non-diabetic CKD, as well as the effects of sodium–glucose cotransporter 2 (SGLT2) and finerenone combination therapy in diabetic nephropathy. |
Introduction
Drug Characteristics and Mechanisms
Drug Characteristics
Mechanisms of Action
Clinical Trial Data in Humans
Steroidal Antagonist Clinical Trials
Study | Inclusion criteria | Duration and size | Intervention | Characteristics | Primary outcome | Secondary outcome |
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ARTS Part B | LVEF ≤ 40% and eGFR 30–60 ml/min/1.73 m2 and potassium ≤ 4.8 mmol/L | 29 ± 2 days 393 participants | Finerenone 2.5 mg q.d., 5 mg q.d., 10 mg q.d., and 5 mg b.i.d. Placebo Spironolactone 25–50 mg q.d.* | Mean age 72.1 ± 7.8 years Mean serum potassium 4.29 (± 0.42) Mean eGFR 47.0 (± 10.00) | Doses of 10 mg q.d. and 5 mg b.i.d. showed significantly greater mean increases in serum potassium compared to placebo. (p = 0.0003) | No significant overall treatment effect on BNP, NT-proBNP, or UACR Smaller rise in serum potassium in every finerenone group vs. spironolactone |
ARTS-DN | T2DM and UACR ≥ 30 mg/g and eGFR > 30 ml/min/1.73 m2 and Potassium ≤ 4.8 mmol/L | 90 days 823 participants | 1.25-, 2.5-, 5-, 7-, 10-, 15-, 20 mg once q.d. added to RAS blocker versus placebo | Mean age 64.2 Mean serum potassium ~ 4.3 mmol/L Mean eGFR ~ 67.6 ml/min/1.73 m2 | Placebo-corrected mean UACR at 90 days was 0.79 in the 7.5 mg group (p = 0.004), 0.76 in the 10 mg group (p = 0.01), 0.67 in the 15 mg group (p < 0.001), and 0.62 in the 20 mg group (p < 0.001) | Hyperkalemia leading to study drug discontinuation was 2.1% in the 7.5 mg group, 0% in the 10 mg group, 3.2% in the 15 mg group, 1.7% in the 20 mg group, and 1.5% for placebo |
ARTS-HF | Chronic HFrEF (LVEF ≤ 40% for the last 12 months) and T2DM plus > 30 ml/min/1.73 m2 or eGFR 30–60 ml/min/1.73 m2 | 90 days 1066 participants | Finerenone 5 mg, 10 mg, 20 mg q.d., versus eplerenone 25 mg q.d.* | Mean age 69.2–72.5 (SD 9.7–10.6 years) Mean NT-proBNP 4517 pg/ml Mean eGFR 53.0 ml/min/1.73 m2 Mean serum potassium 4.1 mmol/L (± 0.42) | > 30% decrease in plasma NT-proBNP from baseline to day 90, occurred in 30.9%, 32.5%, 37.3%, 38.8%, and 34.2% in the 5 mg, 10 mg, 15 mg, 20 mg, and 20 mg finerenone dose groups, respectively, versus 37.2% of the eplerenone group (p = 0.42) | Composite endpoint occurred less frequently in the finerenone 10 mg and 20 mg group vs. the eplerenone group (HR 0.56; p = 0.02) All-cause death (p = 0.062) and CV death (p = 0.011) occurred less frequently in the finerenone versus eplerenone groups |
FIDELIO-DKD | T2DM and UACR 30–300 mg/g + eGFR 25–60 ml/min/1.73 m2 + diabetic retinopathy or UACR 300–5000 + eGFR 25–75 ml/min/1.73 m2 and Potassium ≤ 4.8 mmol/L | 2.6 years 5674 participants | Finerenone 20 mg q.d. vs. placebo, both on maximal tolerate dose of ACEI or ARB# | Mean age 65.6 ± 9.1 years Mean eGFR 44.3 (± 12.6) ml/min/1.73 m2 Median (IQR) UACR 852 (446–1634) mg/g Mean serum potassium 4.37 (± 0.46) mmol/L | Composite outcome of kidney failure, sustained decrease of 40% in the eGFR from baseline, or death from renal causes for finerenone vs. placebo was 17.8% vs. 21.1% (HR 0.82, 95% CI 0.73–0.93, p = 0.0014) | CV death, MI, stroke, hospitalization for HF: 13% vs. 14.8% (p = 0.03) Hyperkalemia leading to discontinuation of the trial regimen was 2.3% in the finerenone group versus 0.9% in the placebo |
FIGARO-DKD | T2DM and UACR 30–300 mg/g + eGFR 25–60 ml/min/1.73 m2 + diabetic retinopathy or UACR 300–5000 + eGFR 25–75 ml/min/1.73 m2 and Potassium ≤ 4.8 mmol/L | 3.4 years 7352 participants | Finerenone 20 mg q.d. vs. placebo, both on maximal tolerate dose of ACEI or ARB# | Mean age 64.1 ± 9.8 years Mean eGFR 67.8 (± 21.7) ml/min/1.73 m2 Median (IQR) UACR 308 (108–740) mg/g Mean serum potassium 4.33 (± 0.43) mmol/L | Composite outcome of CV death, MI, stroke, hospitalization for HF, for finerenone vs. placebo, was 12.4% vs. 14.2% (HR 0.87, 95% CI 0.76–0.98, p = 0.03) | Kidney failure (sustained decrease from baseline of ≥ 40% in GFR, or death from renal cause): 9.5% vs. 10.8% (HR 0.87, 95% CI 0.76–1.01) ESKD: 0.9% vs. 1.3% (HR 0.64, 95% CI 0.41–0.995) Hyperkalemia leading to discontinuation of the trial regimen was 1.2% in the finerenone group versus 0.4% in the placebo |
Phase II Finerenone Clinical Trials
Phase III Finerenone Clinical Trials
Future Directions and Conclusion
Study | Inclusion criteria | Estimated enrollment | Intervention | Estimated study competition date | Primary outcome | Secondary outcome |
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FIND-CKD | CKD with eGFR ≥ 25 to < 90 ml/min/1.73 m2 and UACR ≥ 200–3500 mg/g and Maximally tolerated ACEi/ARB and Potassium ≤ 4.8 mmol/L and HbA1c < 6.5% | 1580 participants | Finerenone 10 mg, 20 mg Placebo | December 8, 2025 | Mean rate of change as measured by the total slope of eGFR from baseline to month 32 | Time to the composite of kidney failure, eGFR decline of ≥ 57%, HF admission, or CV death and Time to composite of kidney failure or eGFR decline of ≥ 57% and Time to composite of HF admission or CV death and Number of participants with treatment-emergent adverse events |
CONFIDE-NCE | CKD and Part A: eGFR 40–90 ml/min/1.73 m2 Part B: eGFR 30–90 ml/min/1.73 m2 and UACR ≥ 300–5000 mg/g and T2DM with HbA1c < 11% and Maximally tolerated ACEi/ARB | 807 participants | Finerenone + empagliflozin Finerenone + placebo → empagliflozin Empagliflozin + placebo → finerenone | December 1, 2023 | Change in UACR with combination therapy group vs. empagliflozin alone and Change in UACR with combination therapy group vs. finerenone alone | Multiple others (see [62]) |
FINE-ARTS | Age > 40 and NYHA class II–IV HF with LVEF ≥ 40% on diuretics and Structural heart abnormalities suggestive of HFpEF and Elevated NT-proBNP or BNP | 5500 participants | Finerenone 10 mg → 20 mg for eGFR ≤ 60 ml/min/1.73 m2 Finerenone 20 mg → 40 mg for eGFR > 60 ml/min/1.73 m2 | May 2, 2024 | Composite outcome: no. of CV deaths and HF events (1st and recurrent events) | Change in TSS from KCCQ and Time to 1st occurrence of composite renal endpoint (decrease in eGFR ≥ 40%, eGFR decline to < 15 ml/min/ 1.73 m2, or initiation of dialysis or transplant) and Time to death from any cause |