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The purpose of this review is to provide a comprehensive understanding of the reasons behind non-steroidal mineralocorticoid receptor antagonist (nsMRA) therapy, summarize the clinical evidence for its effectiveness in treating patients with type 2 diabetes and chronic kidney disease, and offer practical guidance on how and when to initiate nsMRA therapy in conjunction with other treatment options for type 2 diabetes. Finerenone is currently the only approved nsMRA. However, esaxerenone and apararenone have been evaluated as well. Studies show that finerenone significantly reduces the risk of renal and cardiovascular outcomes, whereas esaxerenone and apararenone improve albuminuria. Common adverse effects include hyperkalemia, which can be managed through dose adjustments.
nsMRAs can significantly reduce the risk of cardiorenal progression beyond what can be achieved with glucose and blood pressure control and are now a key component of the recommended treatment for chronic kidney disease associated with type 2 diabetes.
Chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) is a major health challenge associated with a disproportionately high burden of end-stage renal disease, cardiovascular disease and death. This review summarizes the rationale, clinical evidence and practical implementation for non-steroidal mineralocorticoid receptor antagonists (nsMRAs), a drug class now approved and recommended for patients with T2D and CKD at risk of cardiorenal disease progression. Three nsMRAs (finerenone, esaxerenone and apararenone) have been evaluated but finerenone is currently the only approved nsMRA for this indication. Two large-scale, placebo-controlled, Phase 3 studies evaluated finerenone added to a maximally tolerated dose of an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker. Over >2 years of treatment, finerenone was associated with a significant reduction in composite endpoints of renal and cardiovascular outcomes versus placebo. Esaxerenone or apararenone have both shown significant improvements in albuminuria versus placebo. In general, nsMRAs were well tolerated. Hyperkalaemia was the most notable treatment-related adverse event and could generally be managed through serum potassium monitoring and dose adjustments. The nsMRAs are now an important component of recommended treatment for CKD associated with T2D, providing a significant reduction in the risk of cardiorenal progression beyond what can be achieved with glucose and blood pressure control.