Aldosterone inhibitor

An antimineralocorticoid, MCRA, or an aldosterone antagonist, is a diuretic drug which antagonizes the action of aldosterone at mineralocorticoid receptors. This group of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure. Spironolactone, the first member of the class, is also used in the management of hyperaldosteronism (including Conn's syndrome) and female hirsutism (due to additional antiandrogen actions). Most antimineralocorticoids, including spironolactone, are steroidal spirolactones. Finerenone is a nonsteroidal antimineralocorticoid. An antimineralocorticoid, MCRA, or an aldosterone antagonist, is a diuretic drug which antagonizes the action of aldosterone at mineralocorticoid receptors. This group of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure. Spironolactone, the first member of the class, is also used in the management of hyperaldosteronism (including Conn's syndrome) and female hirsutism (due to additional antiandrogen actions). Most antimineralocorticoids, including spironolactone, are steroidal spirolactones. Finerenone is a nonsteroidal antimineralocorticoid. Mineralocorticoid receptor antagonists are diuretic drugs that work primarily on the kidneys. They decrease sodium reabsorption which leads to increased water excretion by the kidneys. By regulating water excretion, mineralocorticoid receptor antagonists lower blood pressure and reduce fluid around the heart which can be very beneficial in some cardiovascular conditions. Mineralocorticoid receptor antagonists have been used for many clinical conditions in the cardiovascular system. It has proven beneficial for diseases like primary aldosteronism, primary and resistant hypertension, heart failure and chronic kidney disease. They are often used with other medications, such as ACE inhibitors or beta blockers. Increased urination is a commonly reported side effect, particularly during the initial phase following treatment initiation, this is mostly transient and tends to reduce with sustained treatment. Common side effects for antimineralocorticoid medications include nausea and vomiting, stomach cramps and diarrhoea. Clinically significant hyperkalemia is possible, and warrants serum potassium monitoring on a periodic basis. The pathology of hyperkalaemia is that antimineralocorticoid medications reduce potassium (K) excretion. Aldosterone is a mineralocorticoid which is synthesized in the adrenal glands. When aldosterone is secreted from the adrenal glands, it binds to the mineralocorticoid receptor in the renal tubule cell and forms a complex. This complex enhances transcription of specific DNA segments in the nucleus, leading to the formation of two protein transporters, Na+/K+ ATPase pump at the basolateral membrane and Na+ channel called ENaC, located at the apical membrane of the renal tubule cell.These protein transporters increase sodium reabsorption and potassium excretion in the distal tubule and the collecting duct of the kidneys. This helps the body to maintain normal volume status and electrolyte balance, increasing the blood pressure. Mineralocorticoid receptor antagonists decrease the aldosterone effect by binding to the mineralocorticoid receptor inhibiting aldosterone. This leads to higher levels of potassium in serum and increased sodium excretion, resulting in decreased body fluid and lower blood pressure. When comparing the pharmacokinetic properties of spironolactone and eplerenone, it is clear that the two drugs differ. Spironolactone has shorter half-life (t1/2 = 1.3-1.4 hours) than eplerenone (t1/2 = 4-6 hours). Eplerenone goes through rapid metabolism by the liver to inactive metabolites (t1/2 = 4-6 hours). However, spironolactone is metabolized to three active metabolites, which give it prolonged activity (13.8 – 16. 5 hours). Spironolactone has a long half-life and is excreted 47-51% through kidneys. Patients with chronic kidney disease therefore require close monitoring when taking the drug. Spironolactone is also eliminated through feces (35-41%). The excretion of eplerenone is 67% through kidneys and 32% through feces. The information about excretion plays a critical role when determining the appropriate doses for patients with renal and/or hepatic dysfunction. It is very important to adjust the doses for patients with renal dysfunction because if they fail to eliminate the drug through their kidneys it could accumulate in the body, causing high concentration of potassium in the blood. Spironolactone and Eplerenone competitively block the binding of aldosterone to the mineralocorticoid receptor and hindering the reabsorption of sodium and chloride ions. The activity of mineralocorticoid antagonists is dependent on the presence of a y-lactone ring on the C-17 position. The C-7 position is also important for activity as substituents there sterically hinder the interaction of C-7-unsubstituted agonists such as aldosterone. Eplerenone is a newer drug that was developed as a spironolactone analog with reduced adverse effects. In addition to the y-lactone ring and the substituent on C-7, eplerenone has a 9α,11α-epoxy group. This group is believed to be the reason why eplerenone has a 20-40-fold lower affinity for the mineralocorticoid receptor than spironolactone. Despite the non-steroidal nature of finerenone which yields a different lipophilicity and polarity profile for this compound, finerenone's affinity toward mineralocorticoid receptors is equal to that of spironolactone and 500 times that of eplerenone, hinting that the steroidal core component of most antimineralocorticoids is not essential for mineralocorticoid receptor affinity.