A New Arrow in the Precision Medicine Quiver for Cardiovascular Disease
It Specifically Blocks A Hormone That Inflames and Scars Organs
Environmental factors like overeating, abdominal fat, smoking, and radiation activate genes that accelerate aging and chronic disease development. Finerenone blocks the effect of a hormone produced by one of these gene products very precisely. Certain specific medications treat cardiovascular disease much more effectively than simply lowering risk factors like diabetes and high blood pressure. I have written extensively here about the special benefits of medications like spironolactone and eplerenone. Inflammation and scar tissue are key factors that damage the arteries and heart. These medications reduce inflammation and scarring while lowering the blood pressure. They block the effect of a hormone that contributes to developing high blood pressure and diabetes. They are precision medicines. Many medications that lower blood pressure are like shotguns. Lowering the pressure is part of a broader impact with more side effects. Spironolactone and eplerenone are like lasers. They specifically block a hormone that directly causes artery disease, heart disease, and high blood pressure. In low doses, they block the biology that causes disease with few side effects in properly selected patients.
These medications were originally thought of as fluid pills and they were used late in disease in large doses for patients retaining lots of water in conditions like cirrhosis and congestive heart failure. These are frail patients with multiple comorbidities. Their late disease and high doses made them much more likely to have side effects like high potassium levels and deteriorating kidney function. That history of side effects led to dramatic underuse of these medications. I take eplerenone myself and have prescribed these medications to hundreds of patients in smaller doses earlier in their disease with very few side effects and excellent results. We have decades of experience with these two medications and, best of all, they are inexpensive. Spironolactone is $4 a month. You can get eplerenone for $18.50 a month. If blood pressure is not controlled with three medications, adding spironolactone lowers the top number by 25 points which brings many more patients to goal. More importantly, spironolactone interferes with fundamental biology that produces faster aging and earlier heart disease.
Now there is a new medication in this class, finerenone, that slows the progression of chronic kidney disease and reduces the number of heart attacks in patients with later disease more safely. Finerenone has a modest impact on blood pressure reduction and most of the benefit seems to be from reducing inflammation and scar formation. This new medication is leading to a substantial volume of research that should bring more attention to this class of drugs.
Some analysts believe finerenone faces serious headwinds that will slow adoption. They point to a greater impact from medications like empagliflozin on congestive heart failure, chronic kidney disease, and mortality. That is true, but it misses the point. These diseases are caused by multiple factors. Finerenone and empagliflozin reduce inflammation and scar tissue by impacting different pathways. Patients on optimal medical treatment combining lisinopril, atorvastatin, metformin, and aspirin reduce their risk of a heart attack 4-fold compared with usual care. The combination of these medications is much more effective than any individual drug. Our task is to decide which combination of medications provide the most benefit, not which individual medication is better than another. Optimal medical treatment that directly reduces scar tissue formation and inflammation is the best treatment for cardiovascular disease.
Finerenone is a new medication that is proven in controlled clinical trials to slow chronic kidney disease progression and to reduce cardiovascular death and other complications. It produces that result by directly interfering with the core biology that causes the disease. That new research should bring more attention to spironolactone and eplerenone which have a similar impact at much less expense. A rational approach to this class of medications would be to use spironolactone earlier in disease when they are less likely to cause complications. Finerenone gives us a medication to use in patients who have high risk of kidney function deterioration and high potassium on this class of medications. This class of medication is woefully underused and hopefully finerenone promotion will increase use of the class.