The headliner: A powerful duo for diabetic nephropathy: finerenone + empagliflozin.

What happens if we start both drugs at once instead of choosing one? The CONFIDENCE trial tested whether initial combination therapy with both drugs is more effective than either drug alone in patients with T2DM and CKD (eGFR 30-90 and albuminuria). After 180 days, combination therapy reduced uACR by 29% more than finerenone and 32% more than empagliflozin alone. Hyperkalemia was reported in 9.3% of the combination group, 11.4% of the finerenone group, and 3.8% of the empagliflozin group. Other safety events such as AKI and symptomatic hypotension were less common. These results hint that dual initiation may be the optimal strategy for kidney protection in high-risk patients. Tune in to Rounds Table to learn more.

The hidden gem: Taming cortisol to tame blood sugar with mifepristone.

What if hard to control diabetes is partly due to hidden hypercortisolism? In this multicenter trial, 136 adults with T2DM (A1C 7.5–11.5% despite multiple medications) and hypercortisolism (by dexamethasone suppression test) were randomized to mifepristone (a glucocorticoid receptor antagonist) or placebo for 24 weeks. Patients on mifepristone saw a >1.3% greater drop in A1C, an average 5 kg weight loss, and 5 cm reduction in waist circumference compared to placebo. However, almost half of participants on mifepristone discontinued therapy, and >10% of participants on mifepristone experienced adverse events, including hypokalemia, fatigue, dizziness, nausea, vomiting, and peripheral edema.

The take home points: 

[1] Finerenone + empagliflozin led to a 29-32% greater reduction in uACR compared with either drug alone.

[2] Mifepristone, compared to placebo, lowered A1C by ~1.3% and reduced weight/waist circumference in T2DM with hypercortisolism.