Edgar Lerma, MD

Exploring the Cardiovascular Benefits, Potential of Finerenone

Management of chronic kidney disease among patients with type 2 diabetes has undergone significant change in the last decade. Once handcuffed by a lack of safe and efficacious options, changing standards of care coming as the result of pharmacotherapeutic advancement have ushered in a new era of management for this patient population.

This change has been spearheaded by 2 particular classes—a familiar face in the form of SGLT2 inhibitors and the novel nonsteroidal mineralocorticoid receptor antagonist (nsMRA) finerenone (Kerendia), which received approval in July 2021 for reducing the risk of sustained eGFR decline, kidney failure, cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in adult patients with chronic kidney disease associated with type 2 diabetes.

Finerenone first captivated the attention of nephrologists, endocrinologists, and other providers managing patients with type 2 diabetes with the release of data from the FIDELIO-DKD and FIGARO-DKD trials. The number of specialists captivated by the agent and its potential benefit grew with the release of data surrounding the cardiovascular benefits among patients with heart failure observed within the FINEARTS-HF trial at the European Society of Cardiology Congress 2024.

In this segment, which is part 5 of a 5-part series, discussants Edgar Lerma, MD, a nephrologist, and Anuradha Lala-Trindade, MD, a cardiologist, dive into the cardiovascular benefits highlighted in the FINEARTS-HF trial with finerenone, specifically its impact on heart failure with preserved ejection fraction (HFpEF). Lala-Trindade elaborates on the historical challenges of treating HFpEF, noting that earlier trials with steroidal MRAs like spironolactone showed mixed results. However, finerenone demonstrated a significant reduction in cardiovascular death and heart failure hospitalizations, marking a substantial advancement for both heart and kidney health in HFpEF patients.

They discuss the paradigm shift in treatment approaches—favoring simultaneous, low-dose initiation of all four heart failure “pillars” rather than sequential dosing. Lala-Trindade points to finerenone’s unique, manageable side-effect profile, particularly its lower risk of hyperkalemia, as promising for broader applicability. They conclude with a look at the practical questions surrounding accessibility and cost, noting the need for more data on the value finerenone may add compared to traditional MRAs.

 a clinical professor of Medicine in the Section of Nephrology at the University of Illinois at Chicago and a nephrologist with Associates In Nephrology based in Chicago.

 the director of Heart Failure Research, program director of the Advanced Heart Failure and Transplant Fellowship, and associate professor of Medicine at The Mount Sinai Fuster Heart Hospital & Department of Population Health Science and Policy.

Relevant disclosures for Lerma include Akebia, Astra Zeneca, Bayer, Boehringer Ingelheim, Glaxo Smith Kline, Otsuka, Travere, Vifor, and Fresenius. Relevant disclosures for Lala-Trindade include Merck, AstraZeneca, Cytokinetics, and Novartis.

Campbell P. Finerenone (Kerendia) approved for chronic kidney disease associated with type 2 diabetes. HCP Live. July 9, 2021. Accessed October 23, 2024. https://www.hcplive.com/view/finerenone-kerendia-approved-chronic-kidney-disease-associated-with-type-2-diabetes.

Campbell P. FDA updates Finerenone label to reflect Cardiovascular Outcomes Data. HCP Live. September 8, 2022. Accessed October 23, 2024. https://www.hcplive.com/view/fda-updates-finerenone-label-to-reflect-cardiovascular-outcomes-data.

Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. 

. Published online September 1, 2024. doi:10.1056/NEJMoa2407107

Videos

In the final part of this 5-part series, Lala-Trindade discusses the findings of the FINEARTS-HF trial and how it might inform use of finerenone. 

Applying guideline directed management in CKD care

In this segment, which is part 4 of a 5-part series, discussants Edgar Lerma, MD, a nephrologist, and Anuradha Lala-Trindade, MD, a cardiologist, explore the substantial impact recent guideline updates have had on chronic kidney disease treatment strategies. Lerma details how clinicians increasingly employ an integrated approach, utilizing ACE inhibitors or ARBs, SGLT2 inhibitors, and finerenone as part of a multi-step, pillar-based strategy to slow chronic kidney disease progression. He notes that traditional protocols involve sequentially adding each treatment every 3 to 6 months, but recent discussions in publications, like one in 

, propose accelerated options. These accelerated approaches may be more appropriate for high-risk patients, where clinicians can implement all therapies simultaneously to swiftly mitigate cardiovascular and renal complications.

Lerma also addresses the ongoing concern around hyperkalemia, especially when using mineralocorticoid receptor antagonists, which remains a potential side effect. He shares his anticipation for the FIND-CKD study, which may extend finerenone’s applications beyond diabetic chronic kidney disease, allowing more chronic kidney disease patients to benefit from its reno-protective effects.

In part 4 of this 5-part series, discussants explore the influence of recent guidelines on changing standards of CKD care.

Applying Recent Guidelines, 4-Pillared Approach to CKD Care

Addressing cardiovascular risk in CKD care

In this segment, which is part 3 of a 5-part series, discussants Edgar Lerma, MD, a nephrologist, and Anuradha Lala-Trindade, MD, a cardiologist, delve into the updated clinical guidelines for managing chronic kidney disease (CKD), especially among patients with type 2 diabetes and elevated cardiovascular risk. Lerma emphasizes the KDIGO guidelines, which now endorse finerenone as an effective treatment option following results from the FIDELIO and FIGARO studies. 

He outlines the modern 4-pillar approach to managing diabetic kidney disease, which includes Metformin, ACE inhibitors or ARBs, SGLT2 inhibitors, and finerenone. Each drug offers unique cardio-renal benefits, working through different mechanisms to slow chronic kidney disease progression and reduce complications. Lerma also stresses the essential role of primary care providers as first responders in identifying at-risk patients, fostering early intervention with this comprehensive, multi-disciplinary approach.

Chronic kidney disease management in type 2 diabetes has evolved significantly due to pharmacotherapeutic advancements, particularly with SGLT2 inhibitors and the novel nsMRA finerenone. Finerenone, approved in 2021, has shown efficacy in reducing risks associated with kidney and cardiovascular complications. The FIDELIO-DKD, FIGARO-DKD, and FINEARTS-HF trials have highlighted its benefits. Updated KDIGO guidelines now recommend a 4-pillar approach, including Metformin, ACE inhibitors or ARBs, SGLT2 inhibitors, and finerenone, emphasizing the role of primary care providers in early intervention.

In part 3 of this 5-part series, Lerma discusses recent updates in the management of chronic kidney disease in people with type 2 diabetes. 

Addressing Cardiovascular Risk in CKD Patients

Rethinking CKD an CVD Care, nsMRA and MRAs

In this segment, which is part 2 of a 5-part series, discussants Edgar Lerma, MD, a nephrologist, and Anuradha Lala-Trindade, MD, a cardiologist, explore the unique features of finerenone as a nsMRA, contrasting it with traditional MRAs like spironolactone. Lala-Trindade highlights that finerenone's increased selectivity for the mineralocorticoid receptor and non-steroidal structure help reduce hormonal side effects common with other MRAs. Additionally, finerenone’s balanced distribution between cardiac and renal tissues may support its dual kidney and cardiovascular benefits, unlike spironolactone, which primarily benefits renal outcomes. 

Lala-Trindade further explains finerenone's potential for anti-fibrotic and anti-inflammatory effects in both organs and suggests that its hyperkalemia risk may be more manageable in chronic kidney disease patients, making it a promising option in this population.

Chronic kidney disease management in type 2 diabetes has evolved significantly due to pharmacotherapeutic advancements, particularly with SGLT2 inhibitors and the novel nsMRA, finerenone. Approved in 2021, finerenone reduces risks of eGFR decline, kidney failure, and cardiovascular events. It gained attention through the FIDELIO-DKD, FIGARO-DKD, and FINEARTS-HF trials. Finerenone's selectivity and non-steroidal structure minimize hormonal side effects, offering dual kidney and cardiovascular benefits. Its anti-fibrotic and anti-inflammatory potential, along with manageable hyperkalemia risk, make it promising for chronic kidney disease patients.

In part 2 of this 5-part series, Lerma and Lala-Trindade discuss the key differences in MoA for nsMRA and MRAs.

Edgar Lerma, MD

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