Combining four pillars of therapy (RAS blockers, SGLT-2 inhibitors, finerenone, and semaglutide) provides additive cardiorenal protection for patients with diabetic kidney disease.
Does a four-pillar therapeutic approach improve cardiorenal outcomes in patients with diabetic kidney disease compared to standard RAS blockade alone?
The management of diabetic kidney disease has evolved to a four-pillar approach (RAS blockers, SGLT2 inhibitors, finerenone, and GLP-1 receptor agonists) to maximize cardiorenal protection.
Abstract Chronic kidney disease (CKD) is the most common comorbidity in patients with type 2 diabetes (T2D), and its presence substantially magnifies the risk for adverse cardiorenal outcomes. For nearly 20 years, the pharmacological blockade of the renin–angiotensin system (RAS) was the only pillar of therapy to offer cardiorenal protection in these patients. Over the last 6 years, newer therapies have been added to our therapeutic armamentarium, offering promise for more effective management of the substantial residual cardiorenal risk of these patients. Large Phase 3 clinical trials have demonstrated additive cardiorenal protective benefits of sodium–glucose cotransporter type 2 (SGLT-2) inhibitors, nonsteroidal mineralocorticoid receptor antagonist (MRA) finerenone, and glucagon-like peptide-1 receptor agonist semaglutide relative to placebo in patients with albuminuric CKD and T2D who are receiving standard-of-care treatment with a RAS-blocker. Evidence from the recently completed CONFIDENCE trial suggests that the cardiorenal protective effects are greater in magnitude and overadditive when SGLT-2 inhibitors are used in combination with finerenone. In this study, we build the puzzle of four pillars of therapy for the improvement of cardiorenal outcomes in patients with CKD associated with T2D. We provide evidence from recent randomized trials, and we discuss the concept of combined treatment for maximal efficacy and better tolerability with fewer adverse events.
Kourtidou et al. (Thu,) conducted a review in Diabetic Kidney Disease. Four pillars of therapy (RAS blockers, SGLT-2 inhibitors, finerenone, semaglutide) was evaluated. Combining four pillars of therapy (RAS blockers, SGLT-2 inhibitors, finerenone, and semaglutide) provides additive cardiorenal protection for patients with diabetic kidney disease.