Finerenone

Finerenone: A Novel Nonsteroidal Mineralocorticoid Receptor Antagonist for Cardiorenal Protection

Abstract

Finerenone (BAY 94-8862) is a novel, potent, selective, nonsteroidal mineralocorticoid receptor antagonist (MRA) developed to address the residual cardiorenal risk in patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D), and more recently, heart failure (HF) with preserved or mildly reduced ejection fraction. Unlike traditional steroidal MRAs such as spironolactone and eplerenone, finerenone possesses a unique chemical structure and pharmacological profile that allows for targeted MR blockade with minimal off-target hormonal effects, thereby reducing the incidence of side effects like gynecomastia. Its mechanism involves specific binding to the mineralocorticoid receptor (MR), preventing the recruitment of transcriptional coactivators and subsequently attenuating MR-mediated inflammation and fibrosis, key drivers of cardiorenal disease progression. Pivotal clinical trials, FIDELIO-DKD and FIGARO-DKD, and their pooled analysis, FIDELITY, have demonstrated finerenone's efficacy in significantly reducing the risk of both CKD progression and cardiovascular events in a broad spectrum of patients with T2D and CKD, largely independent of baseline SGLT2 inhibitor use. The FINEARTS-HF trial has further shown its potential in reducing cardiovascular death and heart failure events in patients with HF and a left ventricular ejection fraction $\ge$40%. While finerenone increases the risk of hyperkalemia, a manageable adverse event through established monitoring and dose-adjustment protocols, its overall safety profile is favorable. Finerenone has been incorporated into major international clinical practice guidelines (KDIGO, ADA, ESC) as a crucial component of comprehensive cardiorenal protective strategies. This report details the pharmacology, clinical evidence, safety profile, and therapeutic positioning of finerenone in contemporar