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Professor of Medicine
Director, American Heart Association Comprehensive Hypertension Center
Department of Medicine
University of Chicago Medicine
George L. Bakris, MD, has disclosed that he has received funds for research support from Alnylam, Bayer, Novo Nordisk, Quantum Genomics, and Vascular Dynamics and consulting fees from Alnylam, AstraZeneca, Bayer, Horizon, Ionis, KBP Biosciences, Merck, Quantum Genomics, and Vascular Dynamics.
Should spironolactone be discontinued in favor of finerenone? Should finerenone be prescribed for all patients with diabetic kidney disease? In this commentary, I answer these and other questions from learners who participated in the webinar “Chronic Kidney Disease in Type 2 Diabetes: Contemporary Approaches to Renoprotection.” Slides from the webinar are also available for self-study or to use in your noncommercial presentations.
For patients already prescribed spironolactone, would you stop it in order to start finerenone?
I would say that not everybody starting spironolactone does horribly. If the patient is on spironolactone, their blood pressure is good, they are not having any problems with hyperkalemia, they are not having gynecomastia, and they are doing well, then I would leave them alone. However, if you are going to start a patient, clearly finerenone is preferred because you will avoid issues with side effects, and I think an important point to keep in mind is that there are data supporting finerenone therapy. Finerenone also has other benefits in terms of tolerability and its mechanism of action that spironolactone does not have, and you don’t have excess active metabolites that spironolactone has, etc. Finerenone is not your mother’s spironolactone.
If a patient has a side effect with a sodium-glucose cotransporter-2 inhibitor(SGLT2i)—for example, a genital infection—would you rechallenge with the same agent once resolved, or would you try a different SGLT2i?
There is no question that genital infections are an SGLT2i class side effect. When you have glucose in your urine, you are going to be susceptible to genital infections if you don’t take care of that area, so that really needs to be a top priority. When I’ve asked the few patients who have reported this side effect if they have followed my instructions (ie, they need to keep that region dry and clean, and I propose the use of a cornstarch-based powder, regardless of manufacturer, to absorb moisture), they admit that they did not. Afterwards, when they did follow these instructions, genital infection was not an issue. I think education is the key.
Would you prescribe finerenone for all chronic kidney disease (CKD)/diabetic kidney disease patients, or only those with worsening renal function?
Finerenone is not to be put in the drinking water. This is really a drug to be used in people who (a) for whatever reason, can’t tolerate SGLT2i therapy, or (b) are taking SGLT2 inhibitors or glucagon-like peptide-1 receptor agonists, and albuminuria is still above 300, or need further cardiovascular/renal risk reduction. This later condition would include most people.
Would you use this drug instead of an SGLT2i?
Right now, with the level of data that we have for heart failure and CKD progression, I think you have still got to go to an SGLT2i, if the person needs glycemic control. In contrast, if glycemic control is not a major issue, then finerenone is a reasonable and viable choice. Moreover, there are data showing additive effects between finerenone and SGLT2i on fibrotic and inflammatory mechanisms in animal models. There is no question that evidence is mounting that these drugs work together and help to further reduce the risk of progression. Thus, it is control of underlying risk factors and need for maximum risk reduction when making the choice, and in most cases both are appropriate. That is where nephrologists are today.
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