Clinical Pharmacology for Kerendia
Mechanism Of Action
Finerenone is a nonsteroidal, selective antagonist of the mineralocorticoid receptor (MR), which is activated by aldosterone and cortisol and regulates gene transcription. Finerenone blocks MR mediated sodium reabsorption and MR overactivation in both epithelial (e.g., kidney) and nonepithelial (e.g., heart, and blood vessels) tissues. MR overactivation is thought to contribute to fibrosis and inflammation. Finerenone has a high potency and selectivity for the MR and has no relevant affinity for androgen, progesterone, estrogen, and glucocorticoid receptors.
Pharmacodynamics
In FIDELIO-DKD and FIGARO-DKD, randomized, double-blind, placebo-controlled, multicenter studies in adult patients with chronic kidney disease associated with type 2 diabetes, the placebo-corrected relative reduction in urinary albumin-to-creatinine ratio (UACR) in patients randomized to finerenone was 31% (95% CI 29-34%), and 32% (95% CI 30-35%) respectively at Month 4 and remained stable for the duration of the trial.
In ARTS DN, a randomized, double-blind, placebo-controlled, multicenter phase IIb dose finding study in adults with CKD and T2D, the placebo-corrected relative reduction in UACR at Day 90 was 25% and 38% in patients treated with finerenone 10 mg and 20 mg once daily, respectively.
In patients treated with Kerendia, the mean systolic blood pressure decreased by 3 mmHg and the mean diastolic blood pressure decreased by 1-2 mmHg at month 1, remaining stable thereafter.
Cardiac Electrophysiology
At a dose 4 times the maximum approved recommended dose, finerenone does not prolong the QT interval to any clinically relevant extent.
Pharmacokinetics
Finerenone exposure increased proportionally over a dose range of 1.25 to 80 mg (0.06 to 4 times the maximum approved recommended dosage). Steady state of finerenone was achieved after 2 days of dosing. The estimated steady-state geometric mean Cmax,md was 160 μg/L and steady-state geometric mean AUCτ,md was 686 μg.h/L following administration of finerenone 20 mg to patients.
Absorption
Finerenone is completely absorbed after oral administration but undergoes metabolism resulting in absolute bioavailability of 44%. Finerenone Cmax was achieved between 0.5 and 1.25 hours after dosing.
Effect Of Food
There was no clinically significant effect on finerenone AUC following administration with high fat, high calorie food.
Distribution
The volume of distribution at steady-state (Vss) of finerenone is 52.6 L. Plasma protein binding of finerenone is 92%, primarily to serum albumin, in vitro.
Elimination
The terminal half-life of finerenone is about 2 to 3 hours, and the systemic blood clearance is about 25 L/h.
Metabolism
Finerenone is primarily metabolized by CYP3A4 (90%) and to a lesser extent by CYP2C8 (10%) to inactive metabolites.
Excretion
About 80% of the administered dose is excreted in urine (<1% as unchanged) and approximately 20% in feces (< 0.2% as unchanged).
Specific Populations
There are no clinically significant effects of age (18 to 79 years), sex, race/ethnicity (White, Asian, Black, and Hispanic), or weight (58 to 121 kg) on the pharmacokinetics of finerenone.
Renal Impairment
There were no clinically relevant differences in finerenone AUC or Cmax values in patients with eGFR 15 to < 90 mL/min/1.73m2 compared to eGFR ≥ 90 mL/min/1.73 m2. For dosing recommendations based on eGFR and serum potassium levels see DOSAGE AND ADMINISTRATION.
Hepatic Impairment
There was no clinically significant effect on finerenone exposure in cirrhotic patients with mild hepatic impairment (Child Pugh A).
Finerenone mean AUC was increased by 38% and Cmax was unchanged in cirrhotic patients with moderate hepatic impairment (Child Pugh B) compared to healthy control subjects.
The effect of severe hepatic impairment (Child Pugh C) on finerenone exposure was not studied.
Drug Interaction Studies
Clinical Studies And Model-Informed Approaches
Strong CYP3A Inhibitors
Concomitant use of itraconazole (strong CYP3A4 inhibitor) increased finerenone AUC by >400%.
Moderate CYP3A Inhibitors
Concomitant use of erythromycin (moderate CYP3A4 inhibitor) increased finerenone mean AUC and Cmax by 248% and 88%, respectively.
Weak CYP3A Inhibitors
Concomitant use of amiodarone (weak CYP3A4 inhibitor) increased finerenone AUC by 21%.
Strong or Moderate CYP3A Inducers
Concomitant use of efavirenz (moderate CYP3A4 inducer) and rifampicin (strong CYP3A4 inducer) decreased finerenone AUC by 80% and 90%, respectively.
Other Drugs
There was no clinically significant difference in finerenone pharmacokinetics when used concomitantly with gemfibrozil (strong CYP2C8 inhibitor), omeprazole (proton pump inhibitor), or an aluminium hydroxide and magnesium hydroxide antacid. There were no clinically significant pharmacokinetic differences for either finerenone or concomitant digoxin (P-gp substrate) or warfarin (CYP2C9 substrate). There were no clinically significant differences in the pharmacokinetics of either midazolam (CYP3A4 substrate) or repaglinide (CYP2C8 substrate) when used concomitantly with finerenone. Multiple doses of 40 mg finerenone once-daily had no clinically relevant effect on AUC or Cmax of the BCRP and OATP substrate rosuvastatin.
Clinical Studies
FIDELIO-DKD (NCT: 02540993) and FIGARO-DKD (NCT: 02545049) studies were randomized, double-blind, placebo-controlled, multicenter studies in adult patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). In FIDELIO-DKD, patients needed to either have an UACR of 30 to < 300 mg/g, eGFR 25 to < 60 mL/min/1.73 m2 and diabetic retinopathy, or an UACR of ≥ 300 mg/g and an eGFR of 25 to < 75 mL/min/1.73 m2 to qualify for enrollment. In FIGARO-DKD, patients needed to have an UACR of 30 mg/g to < 300 mg/g and an eGFR of 25 to 90 mL/min/1.73m2, or an UACR ≥ 300 mg/g and an eGFR ≥ 60 mL/min/1.73m2.
Both trials excluded patients with known significant non-diabetic kidney disease. All patients were to have a serum potassium ≤ 4.8 mEq/L at screening and be receiving standard of care background therapy, including a maximum tolerated labeled dose of an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). Patients with a clinical diagnosis of chronic heart failure with reduced ejection fraction and persistent symptoms (New York Heart Association class II to IV) were excluded. The starting dose of Kerendia was based on screening eGFR (10 mg once daily in patients with an eGFR of 25 to < 60 mL/min/1.73 m2 and 20 mg once daily in patients with an eGFR ≥ 60 mL/min/1.73 m2). The dose of Kerendia could be titrated during the study, with a target dose of 20 mg daily.
The primary objective of the FIDELIO-DKD study was to determine whether Kerendia reduced the incidence of a sustained decline in eGFR of ≥ 40%, kidney failure (defined as chronic dialysis, kidney transplantation, or a sustained decrease in eGFR to < 15 mL/min/1.73 m2), or renal death. The secondary outcome was a composite of time to first occurrence of CV death, non-fatal MI, non-fatal stroke or hospitalization for heart failure. The primary objective of the FIGARO-DKD study was to determine whether Kerendia reduced the time to first occurrence of CV death, non-fatal MI, non-fatal stroke or hospitalization for heart failure. The secondary outcome was a composite of time to kidney failure, a sustained decline in eGFR of 40% or more compared to baseline over at least 4 weeks, or renal death.
In FIDELIO-DKD, a total of 5674 patients were randomized to receive Kerendia (N=2833) or placebo (N=2841) and were followed for a median of 2.6 years. The mean age of the study population was 66 years, and 70% of patients were male. This global trial population was 63% White, 25% Asian, and 5% Black (24% Black in the US). At baseline, the mean eGFR was 44 mL/min/1.73m2, with 55% of patients having an eGFR < 45 mL/min/1.73m2. Median urine albuminto-creatinine ratio (UACR) was 852 mg/g, mean glycated hemoglobin A1c (HbA1c) was 7.7%, and the mean blood pressure was 138/76 mmHg. Approximately 46% of patients had a history of atherosclerotic cardiovascular disease and 8% had a history of heart failure. At baseline, 99.8% of patients were treated with an ACEi or ARB. Approximately 97% were on an antidiabetic agent (insulin [64.1%], biguanides [44%], glucagon-like peptide-1 [GLP-1] receptor agonists [7%], sodium-glucose cotransporter 2 [SGLT2] inhibitors [5%]), 74% were on a statin, and 57% were on an antiplatelet agent.
In FIGARO-DKD, a total of 7352 patients were randomized to receive Kerendia (N=3683) or placebo (N=3666) and were followed for 3.4 years. As compared to FIDELIO-DKD, baseline eGFR was higher in FIGARO-DKD (mean eGFR 68, with 62% of patients having an eGFR ≥ 60 mL/min/1.73 m2) and median UACR was lower (308 mg/g). Otherwise, baseline patient characteristics and background therapies were similar in the two trials.
In FIDELIO-DKD, Kerendia reduced the incidence of the primary composite endpoint of a sustained decline in eGFR of ≥ 40%, kidney failure, or renal death (HR 0.82, 95% CI 0.73-0.93, p=0.001) as shown in Table 4 and Figure 1. The treatment effect reflected a reduction in a sustained decline in eGFR of ≥ 40% and progression to kidney failure. There were few renal deaths during the trial. Kerendia also reduced the incidence of the secondary composite endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (MI), non-fatal stroke or hospitalization for heart failure (HR 0.86, 95% CI 0.75-0.99, p=0.034) as shown in Table 4 and Figure 3. The treatment effect reflected a reduction in CV death, non-fatal MI, and hospitalization for heart failure. The treatment effect on the primary and secondary composite endpoints was generally consistent across subgroups.
In FIGARO-DKD, Kerendia reduced the incidence of the primary composite endpoint of CV death, non-fatal MI, nonfatal stroke or hospitalization for heart failure (HR 0.87, 95% CI 0.76-0.98, p = 0.026) as shown in Table 4 and Figure 4. The treatment effect was mainly driven by an effect on hospitalization for heart failure, though CV death also contributed to the treatment effect. The treatment effect on the primary composite endpoint was generally consistent across subgroups, including patients with and without pre-existing cardiovascular disease. The findings for the renal composite endpoint are shown in Table 4 and Figure 2.
Table 4: Analysis of the Primary and Secondary Time-to-Event Endpoints (and their Individual Components) in Phase 3 Studies FIDELIO-DKD and FIGARO-DKD
|
FIDELIO-DKD |
FIGARO-DKD |
Kerendia
N=2833 |
Placebo
N=2841 |
Treatment Effect Kerendia / Placebo |
|
Kerendia
N=3686 |
Placebo
N=3666 |
Treatment Effect Kerendia / Placebo |
| Time-to-event Endpoints: |
Event Rate
(100 pt-yr) |
Event Rate
(100 pt-yr) |
Hazard Ratio (95% CI) |
p-value |
Event Rate
(100 pt-yr) |
Event Rate
(100 pt-yr) |
Hazard Ratio (95% CI) |
p-value |
| Composite of kidney failure, sustained eGFR decline ≥40% or renal death |
7.6 |
9.1 |
0.82
[0.73; 0.93] |
0.001 |
3.2 |
3.6 |
0.87
[0.76; 1.01] |
- |
| Kidney failure |
3.0 |
3.4 |
0.87
[0.72; 1.05] |
- |
0.4 |
0.5 |
0.72
[0.49;1.05] |
- |
| Sustained eGFR decline ≥40% |
7.2 |
8.7 |
0.81
[0.72; 0.92] |
- |
3.0 |
3.5 |
0.87
[0.75;>1.00] |
- |
| Renal death |
- |
- |
- |
- |
- |
- |
- |
- |
| Composite of CV death, non-fatal MI, non-fatal stroke or hospitalization for heart failure |
5.1 |
5.9 |
0.86
[0.75; 0.99] |
0.034 |
3.9 |
4.5 |
0.87
[0.76; 0.98] |
0.026 |
| CV death |
1.7 |
2.0 |
0.86
[0.68;1.08] |
- |
1.6 |
1.7 |
0.90
[0.74; 1.09] |
- |
| Non-fatal MI |
0.9 |
1.2 |
0.80
[0.58;1.09] |
- |
0.9 |
0.9 |
0.99
[0.76; 1.31] |
- |
| Non-fatal stroke |
1.2 |
1.2 |
1.03
[0.76;1.38] |
- |
0.9 |
0.9 |
0.97
[0.74; 1.26] |
- |
| Hospitalization for heart failure |
1.9 |
2.2 |
0.86
[0.68;1.08] |
- |
1.0 |
1.4 |
0.71
[0.56; 0.90] |
- |
p-value: two-sided p-value from stratified logrank test
CI = confidence interval, CV = cardiovascular, eGFR = estimated glomerular filtration rate, MI = myocardial infarction, N = number of subjects, n = number of subjects with event, pt-yr = patient year.
NOTE: Time to first event was analyzed in a Cox proportional hazards model. For patients with multiple events, only the first event contributed to the composite endpoint. Sums of the numbers of first events for the single components do not add up to the numbers of events in the composite endpoint. |
Figure 1: Time to first occurrence of kidney failure, sustained decline in eGFR ≥ 40% from baseline, or renal death in the FIDELIO-DKD study
Figure 2: Time to first occurrence of kidney failure, sustained decline in eGFR ≥ 40% from baseline, or renal death in the FIGARO-DKD study
Figure 3: Time to first occurrence of CV death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure in the FIDELIO-DKD study
Figure 4: Time to first occurrence of CV death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure in the FIGARO-DKD study