Physicians' Academy for Cardiovascular Education

Ambulatory SBP reduction with nonsteroidal MRA in patients with T2DM and CKD

Effect of finerenone on ambulatory blood pressure in chronic kidney disease in type 2 diabetes

Literature - Agarwal R, Ruilope LM, Ruiz-Hurtado G, et al. - J Hypertens. 2023 Feb 1;41(2):295-302. doi: 10.1097/HJH.0000000000003330

Introduction and methods


The phase 3 trials FIDELIO-DKD and FIGARO-DKD recently showed that the selective, nonsteroidal MRA finerenone delayed progression of CKD and reduced the risk of CV events in patients with both T2DM and CKD [1,2]. The hemodynamic effects of finerenone are not clear as blood pressure (BP) data were limited to office measurements in these trials and few other data on this subject exist.

Aim of the study

The authors investigated the effect of finerenone ≥10 mg on 24-hour ambulatory BP and compared this outcome to the time course of concurrently obtained office BP in patients with T2DM and CKD.


The ARTS-DN (Mineralocorticoid Receptor Antagonist Tolerability Study-Diabetic Nephropathy) trial was a multicenter, double-blind, placebo-controlled, dose-finding, parallel-group, phase 2b RCT in which 821 patients with T2DM, urine albumin-to-creatinine ratio ≥30 mg/g, and eGFR 30–90 mL/min per 1.73 m²were randomized to finerenone 1.25–20 mg or placebo (once daily in the morning) for 90 days [3]. The primary aim of this trial was to assess the effects of finerenone on albuminuria. The current substudy analysis included a subset of patients for whom ambulatory BP measurements were available (n=240).

24-hour ambulatory BP monitoring (ABPM) was performed at screening and at 60 and 90 days. Office BP measurements were conducted at baseline, at 1, 7, 30, 60 and 90 days, and at the follow-up visit (after 120 days).

Main results

Change in office systolic BP

Changes in 24-hour, daytime, and nighttime ambulatory systolic BP

24-hour time course of ambulatory systolic BP


This substudy analysis of the ARTS-DN trial in 240 patients with T2DM and CKD showed that finerenone (dosed once daily in the morning) reduced 24-hour, daytime, and nighttime SBP from baseline to 60 and/or 90 days compared with placebo. Although finerenone has a short plasma half-life (~2–3 hours) and no active metabolites, the SBP reductions at 90 days were persistent over 24 hours, including during the night.

According to the authors, their results suggested “finerenone has hemodynamic effects in patients with CKD and T2D[M] that are unlikely to be attributable to its pharmacokinetic properties. These hemodynamic effects provide a biological basis for greater incidence of hypotension, a lower incidence of hypertension, and an early separation in curves of the time to first CV events seen with finerenone.”


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