Open access peer-reviewed chapter

Advances in the Development of Non-steroidal Mineralocorticoid-receptor Antagonists

Written By

Felipe L. Pérez-Gordillo, Maria Jesús Pérez de Vega, Guillermo Gerona-Navarro, Yoel Rodríguez, Diego Alvarez de la Rosa, Rosario González-Muñiz and Mercedes Martín-Martínez

Reviewed: 05 July 2019 Published: 25 September 2019

DOI: 10.5772/intechopen.88417

From the Monograph

Aldosterone-Mineralocorticoid Receptor - Cell Biology to Translational Medicine

Edited by Brian Harvey and Frederic Jaisser

Chapter metrics overview

1,176 Chapter Downloads

View Full Metrics


The mineralocorticoid receptor (MR) belongs to the nuclear receptor superfamily and regulates body fluid and electrolyte balance. In the last years, much effort has been put into the development of non-steroidal MR antagonists that overcome the side effects of the marketed steroid drugs, and can be used for the treatment of hypertension and heart failure, among others. Initially, MR was identified in epithelial cells, however it also plays important roles in non-epithelial tissues. In this sense, it is of interest to discover ligands that might induce different MR conformational changes, leading to specific coregulator interactions, which could confer tissue-specific effects. Different series of non-steroidal ligands with diverse central scaffolds has been described, which shows antihypertensive and cardiorenal protective effects. This review covers a description of different non-steroidal MR antagonist families, with special focus on compounds under clinical development. The analysis of the three-dimensional (3D) structures of non-steroidal MR antagonists in complex with the MR ligand-binding domain (LBD), recently reported, highlights the interactions crucial for binding. The structure-activity relationships of known ligands, together with the insights provided by the 3D structures of ligand - LBD MR complexes, could help in the development of non-steroidal MR antagonists with improved properties.


  • mineralocorticoid receptor
  • MR antagonist
  • structure-activity relationship
  • clinical trials

1. Introduction

The mineralocorticoid receptor (MR) transduces the effects of the steroid hormone aldosterone on mineral ion homeostasis, extracellular volume, and blood pressure mainly by regulating kidney Na+ reabsorption and K+ and H+ excretion [1]. In addition, MR can also act as a high-affinity receptor for glucocorticoids. In aldosterone target tissues such as the kidney distal nephron, glucocorticoid-mediated activation of MR is limited by co-expression of 11-β-hydroxysteroid dehydrogenase type II (11ßHSD2), which enzymatically limits access of glucocorticoids to the receptor [2]. High corticosteroid circulating levels can overcome this mechanism, producing mineralocorticoid-like effects. Furthermore, MR tissue distribution is much broader than originally expected, and in many cells it is unclear if there are any mechanisms at all providing aldosterone selectivity over glucocorticoids [3]. It is thus reasonable to assume that both aldosterone and glucocorticoids can activate MR in a cell type-specific fashion.

The role of MR in blood pressure regulation and K+ homeostasis has been therapeutically exploited using steroid analogs with competitive inhibitory activity. This strategy is commonly used for treating primary aldosteronism and additional clinical situations where a decrease in extracellular volume is advantageous, such as essential hypertension and edema associated with congestive heart failure or cirrhosis [4]. The interest in MR antagonists has greatly increased in the past two decades. The unexpectedly broad tissue distribution of MR prompted research on possible additional physiological and pathological roles for this receptor [5]. It is now clear that MR has important contributions to the development of fibrosis [6], inflammation [7], and oxidative stress [8], greatly expanding the potential role of MR in human disease. Aldosterone/MR signaling associated with high NaCl intake produces cardiac, vascular, and renal injury independent of changes in blood pressure [9]. The benefits of MR antagonists in patients with heart failure resulted in the approval of their use to treat this condition [10]. Furthermore adipocyte MR activation may be implicated in obesity and metabolic syndrome, opening new possible applications to MR antagonists [11]. New roles of MR in ocular or skin diseases have led to new uses of MR antagonists [5, 12].

Unfortunately, therapeutic interventions aimed at limiting MR actions are hampered by adverse side effects. Ligand-binding domain (LBD) sequence conservation between MR and glucocorticoid, progesterone, and androgen receptors (GR, PR, and AR) implies frequent ligand cross-reactivity. For instance, spironolactone is structurally related to progesterone and acts as a PR agonist and AR antagonist, leading to frequent adverse sexual side effects. This has largely been solved by the use of eplerenone, a second-generation MR antagonist with weaker affinity for AR and PR [13]. The use of MR antagonists is further complicated by their potassium-sparing characteristics. While this activity is desirable in the context of hypertensive patients treated with loop diuretics [14], it is associated with higher mortality in patients with heart failure [15]. Therefore, there is a clear need for developing selective MR modulators that preferably have a nonsteroidal nature and may present selective beneficial actions without undesired side effects [4].

This review aims to delineate the different chemical structural families that have led to MR nonsteroidal antagonists. For a more comprehensive data regarding different compounds in each family, a recent review by Martin-Martinez et al. can be of interest [16]. In this chapter, we also focused on those compounds that entered clinical trials and in the known three-dimensional (3D) structure of nonsteroidal compounds bound to the LBD of MR.


2. Nonsteroidal MR ligands

An active search for nonsteroidal MR antagonists has been carried out to overcome the side effects observed with steroidal drugs. In general, starting from a high-throughput screening (HTS), an initial hit compound is identified. Next, a hit to lead optimization process, quite frequently through a structure-based design, leads to compounds with improved binding affinity and pharmacokinetic (PK) properties. Examples of different nonsteroidal MR antagonist families are included in this section. In addition, to facilitate a better understanding through the manuscript, the 2D structures of compounds under clinical trials and/or known 3D structures are described in Sections 3 and 4.

The 1,4-dihydropyridine ring (DHP) has proven to be a rather interesting scaffold and have been explored by Pfizer, Bayer Pharma, and Merck (Figure 1). Their studies showed the importance of the stereochemistry at DHP C4 [17, 18], as well as a free DHP amino group [18, 19]. Pfizer described a series of DHP with a phenyl group at C4, with small, nonpolar substituents like F, Cl, or CF3 suitable at this ring [19]. Although a voluminous substituent at C2 led, in general, to lower affinity, the incorporation of tetrazolmethyl group as in 1 resulted in better physicochemical properties while maintaining potency and selectivity over other nuclear hormone receptors (NHRs, IC50 > 300 nM for PR, GR, and AR). Compound 1 reduces blood pressure and renal injury in rats. On the other hand, Bayer Pharma, starting from an HTS, and the subsequent optimization, identified DHP 2 (BR-4628) with a chromenone at DHP C4 as a potent MR antagonist with more that 150-fold selectivity over GR, AR and PR and a good PK profile in rats [18]. BR-4628 has been proposed to be a bulky antagonist with a passive mechanism. Docking studies shown that BR-4628 5-acetyl and C6-methyl groups protrude toward the MR helix H12. However, there is also a loss of contacts within this region compared to steroid agonist, which might account for the inability of this complex to recruit co-regulators [20]. Interestingly, for several steroid antagonists, a mechanism based on loss of contacts has been proposed with helix H12 leading to a destabilization of the AF2 region, which is involved in co-regulator interaction [21]. The moderate selectivity of BR-4628 versus L-type Ca2+ channels prevented further development. Afterwards, Bayer studies led to a series of heterobicyclic analogs, from which a naphthyridine derivative, named finerenone (17, see Figure 5), entered clinical trials. DHP has also been the focus of Merck, which patented a series of sub-micromolar binding affinity DHP, as derivative 3 [22].

Figure 1.

DHP and five-membered heterocyclic rings as scaffolds in MR ligands. aCell-based assays. bCompetitive binding assays.

Five-membered heterocyclic rings have also proven to be quite successful moieties in the search of nonsteroidal MR antagonists. In particular, the pyrrole ring is found in a series of MR ligands developed by Exelixis and Daiichi Sankyo, such as CS-3150 that entered clinical trials (18, Figure 5) [23]. On the other hand, the pyrazoline ring has been explored by Pfizer, as in compound 4 (Figure 1), where the R enantiomer showed higher potency. Compound 4, with more than 500-fold selectivity over PR, and at least 2000-fold over GR and AR, behaves as an antagonist increasing the urinary Na+/K+ ratio in rats [24]. The 3-phenyl-pyrazoline cyclization led to a series of conformational restricted pyrazoline derivatives, one of them entered clinical trials, PF-3882845 (14, Figure 5) [25]. Additionally, starting from an HTS, Merck identified a series of MR antagonists based on the oxazolidine-2,4-dione scaffold. Several derivatives showed potent MR affinity, as compound 5 (Figure 1), which has significant selectivity versus other NHRs (IC50, PR, AR, GR > 5 μm) [26].

On the other hand, it is worth mentioning the benzoxazinone-derived MR ligands, which have been also broadly explored. An analysis of the X-ray crystal structure of compounds with this bicycle bound to MR LBD provided insights regarding their binding determinants to MR, as explained below (Section 4). In general, in these series there is an additional aromatic ring linked to position 6 of the benzoxazinone moiety, either through linear linkers as in Novartis compound 6 [27] or heteroaromatic rings, like in Takeda derivatives 7, 1922 (Figures 2 and 6) [28, 29]. Compound 7 behaves as antagonist and shows good selectivity over GR, PR, and AR (IC50 > 2.5 μM). It is able to decrease urinary Na+/K+ and has a blood pressure-lowering effect similar to that of spironolactone in a DOCA-salt hypertensive rat model. Interestingly, a carbonyl linker led to AstraZeneca benzoxazinone derivative AZD9977, which is currently in clinical trials (15, Figure 5). In a recent publication, AstraZeneca describes the thorough structure and property studies that led to the identification of this clinical candidate [30]. Additionally, a benzoxazinone derivative with a rather different pattern of substituents was developed by Mitsubishi Tanabe Pharma leading to apararenone (16, Figure 5), which is also in clinical trials .

Figure 2.

Benzoxazinone-, indole-, and indazole-derived MR ligands. aCell-based assays. bCompetitive binding assays.

The indole group was also found as part of two series of potent MR antagonists identified by screening methodologies by Eli Lilly (Figure 2). One of them included a 3,3-bisaryloxoindol as central scaffold, where, for example, derivative 8 showed good selectivity over GR, PR, and AR (more than 390-fold) [31]. The other series contained an indole ring, as in compound 9, which was more potent than eplerenone in lowering blood pressure in a rat hypertension model [32]. A related series containing an indazole ring and an aryl sulfonamide were developed by Merck Sharp & Dohme Corp., for example, compound 10 (stereochemistry not disclosed) that showed a good PK profile in rats [33].

Aryl sulfonamide and urea moieties were also found in compounds 11 and 12, developed by Sumitomo Dainippon Pharma and Boehiringer Ingelheim, respectively (Figure 3) [34, 35]. Recently, a novel byaryl sulfonamide-based MR antagonist was identified in an HTS by AstraZeneca (compound 27, Figure 8). A combination of structure–activity relationship (SAR) exploration and X-ray crystal structure determination subsequently guided the design of related MR antagonist 28 and 29 (Figure 8) [36].

Figure 3.

Aryl sulfonamide and urea functionalities in MR ligands. IC50 from competitive binding assays.

Tricyclic scaffolds have also been studied, particularly those containing a central six- or seven-membered ring flanked by differently substituted phenyl moieties. These derivatives are frequently described within patents, and for some of them only scarce pharmacological data is available [16]. Thus, Eli Lilly has developed different families with interesting properties, among them the dibenzooxepine 13 (Figure 4), an MR antagonist, with more than 800-fold selectivity over GR, AR, and PR. Compound 13 was studied in combination with tadalafil, a mild vasodilator, for the treatment of patients with resistant hypertension. These studies showed that their combination led to a greater blood pressure reduction in patients than monotherapies [37]. Some websites associated this compound with LY2623091, which entered clinical trials [38, 39]. Recently, other tricyclic derivatives, with a seven-membered heterocyclic central ring and a benzoxazinone moiety linked to this ring, have been described by Vitae Pharmaceuticals. An example of these latter derivatives is compound 23 whose X-ray crystal structure bound to MR LBD has been solved (Figure 6) [40].

Figure 4.

A tricyclic scaffold in MR antagonist. IC50 from competitive binding assays.


3. Nonsteroidal MR antagonists that entered clinical trials

The effort devoted to the search of nonsteroidal MR antagonist has led, to the best of our knowledge, to seven compounds entering clinical trials [41, 42, 43]. However, two of them, namely, LY2623091 from Eli Lilly and PF03882845 from Pfizer, have been discontinued. Both derivatives are nonsteroidal MR antagonist, selective, and oral bioavailable. LY262309 entered two phase II clinical studies, for patients with chronic kidney disease (CKD) or high blood pressure [44, 45, 46], but according to Adis Insight database, this compound was discontinued [47]. PF03882845 (14, Figure 5) entered phase I clinical studies in patients with type 2 diabetic nephropathy; however the study terminated prematurely due to strategic reasons, according to Pfizer [48, 49].

Figure 5.

MR antagonist that entered clinical trials. aCell-based assays. bBinding-based assays.

Recently, AZD9977 from AstraZeneca and KBP-5074 from KBP Biosciences have entered clinical trials. AZD9977 (15, Figure 5) is a partial MR antagonist in vitro, with cardiorenal protection [50]. It separates organ-protective effects from urinary electrolyte excretion in rodent models, likely reducing hyperkalemia risk. This profile seems to be due to a different pattern of interactions with MR, particularly affecting Met777, which influences the AF2 surface. The AF2 region is key for co-regulator interaction, and a different recruitment compared to eplerenone was observed for this compound. Initial clinical studies showed that AZD9977 was safe and well tolerated; however, compared with rodents, in humans the effects on urinary Na+/K+ were similar to eplerenone [51]. Yet four phase I clinical trials have been completed with this compound, all in the United Kingdom, the last ones in June 2018 [52]. On the other hand, KBP-5074 is a highly selective and potent MR antagonist. Phase I and IIa studies have been completed in the United States [53]. These studies evaluated safety, tolerability, and PK in healthy volunteers and patients with CKD or renal impairment. A phase IIb trial started in April 2018 for patients with uncontrolled hypertension and advanced CKD.

To date, the most advanced compounds are esaxerenone (CS-3150), finerenone (BAY94-8862), and apararenone (MT-3995). Apararenone (16, Figure 5, Table 1) [42, 54, 55], developed by Mitsubishi Tanabe Pharma Corporation, has completed seven phase II clinical trials for the treatment of diabetic nephropathy; some studies include patients also with albuminuria or with albuminuria and moderately decreased in glomerular filtration rate. There is an active phase II clinical trial in patients with nonalcoholic steatohepatitis (NASH), which will be completed by April 2019.

NCT numberPhaseEnrollmentStudy start/completionLocation
Efficacy and safety of MT-3995 in patients with NASH
NCT02923154II40September 2016/April 2019Japan
Efficacy and safety of MT-3995 in patients with diabetic nephropathy
NCT02517320II293July 2015/January 2017Japan
An extended treatment study of MT-3995 in patients with diabetic nephropathy
NCT02676401II241February 2016/August 2017aJapan

Table 1.

Apararenone (MT-3995) phase II clinical trials completion after 2016 [55].

Primary completion.

Finerenone (17, Figure 5) is a potent, oral bioavailable MR antagonist from Bayer, with more than 500-fold selectivity over AR, PR, or GR [18]. Structural studies indicated that MR Ala773 and Ser810 are the reasons behind its selectivity. These studies also suggested that it is a bulky antagonist that inactivates MR producing a protrusion of LBD helix H12 and avoiding the recruitment of coactivators [56]. Furthermore, it has been found that finerenone modulates MR cofactor binding different from eplerenone. This selective modulation has been suggested as the molecular basis from the different clinical behavior of finerenone compared with eplerenone [57]. Interestingly, it behaves as an antagonist of S810L MR, a mutant that leads to a severe form of familiar hypertension. In preclinical models finerenone showed better cardiorenal end-organ protection than spironolactone or eplerenone [58]. Its good properties prompted to further advance it to clinical trials (Table 2). In a phase II trial (mineralocorticoid receptor antagonist tolerability study (ARTS)) including subjects with chronic heart failure and mild or moderate CKD, finerenone was at least as effective as spironolactone in decreasing ventricular remodeling but with lower incidence of hyperkalemia and renal adverse effects [59, 60]. The fact that finerenone distributes equally between cardiac and renal tissues in rats, whereas spironolactone and eplerenone show a higher kidney accumulation, might explain the lower incidence of hyperkalemia. The lower accumulation, together with its minimal renal elimination, might open opportunities for the treatment of patients with renal impairment [61, 62]. A subsequent phase II study (ARTS-diabetic nephropathy (ARTS-DN)) analyzed the safety and efficacy of finerenone in subjects with type 2 diabetes mellitus (T2DM) and diabetic nephropathy. In this study the urinary albumin to creatinine ratio (UACR) decreased in patients treated with finerenone compared to placebo, with no significant differences in adverse effects observed between both groups [63, 64]. In the ARTS-heart failure trial (ARTS-HF), different doses of finerenone and eplerenone were compared for patients with worsening heart failure with concomitant T2DM and/or CKD. Finerenone (10–20 mg dose) showed better outcome, including death, cardiovascular hospitalization, or emergency visit [65]. There are two large trials on going (FIDELIO-DKD, FIGARO-DKD) including subjects with T2DM and diabetic kidney disease (DKD) at doses of 10 or 20 mg of finerenone.

NCT numberPhaseEnrollmentStudy start/completionLocation
Efficacy and safety of finerenone in subjects with T2DM and DKD
III4800September 2015/October 2019Global
Efficacy and safety of finerenone in subjects with T2DM and the clinical diagnosis of DKD
III6400September 2015/February 2020Global
Efficacy and safety of oral doses of BAY94-8862 in subjects with T2DM and the clinical diagnosis of diabetic nephropathy
II823June 2013/August 2014Global
II96October 2013/November 2014Japan
Phase IIb safety and efficacy of different oral doses of BAY94-8862 in subjects with worsening chronic heart failure and left ventricular systolic dysfunction and either T2DM with or without CKD or CKD alone
II1058June 2013/December 2014Global
II72November 2013/February 2015Japan
BAY94–8862 dose finding trial in subjects with chronic heart failure and mild (part A) or moderate (part B) CKD
II458May 2011/July 2012Global

Table 2.

Finerenone (BAY94-8862) phase III and phase II ARTS clinical trials [68].

Recently, the administration of finerenone to a rat model of metabolic syndrome (Zucker fa/fa) showed that finerenone exerted cardiac protection, as it has been previously described for spironolactone. However, only finerenone afforded renal protection [66, 67].

Esaxerenone (18, Figure 5) is a highly potent and selective MR antagonist, with at least 1000-fold higher selectivity over AR, PR, or GR. It has also long-lasting oral activity, longer than steroidal drugs [23]. In addition, it has shown antihypertensive and cardiorenal protective effects in Dahl salt-sensitive hypertensive rats with superior potency than spironolactone or eplerenone and no apparent hyperkalemia [69]. The similar balanced distribution of esaxerenone to the kidney and heart in rats might be the reason of its higher organ-protective effects than marketed drugs. A subsequent study was performed with a model of hypertensive rats, based on a synthetic mineralocorticoid, deoxycorticosterone acetate (DOCA), that induces hypertension and renal injury in combination with salt loading (DOCA rats). In this model, esaxerenone was able to prevent hypertension and the development of renal damage. It has also been suggested that its beneficial actions on renal injury cannot be only attributed to its antihypertensive effect but also to direct renal protection through antifibrotic, anti-inflammatory, and antioxidant actions. Interestingly, this compound is also able to restore the established renal damage in DOCA rats [70]. Esaxerenone was identified by Exelixis’ research collaboration with Daiichi Sankyo. In 2006 they signed an agreement in which Daiichi Sankyo was granted a worldwide license. To date, five phase III studies have been completed related to hypertension, some of them in addition to type 2 diabetes and albuminuria or moderate renal impairment. The combination with other antihypertensive therapies has also been studied (Table 3). In February 2018, Exelixis announced that Daiichi Sankyo had submitted a regulatory application to the Japanese Pharmaceutical and Medical Devices Agency for esaxerenone to be approved for the treatment of hypertension [71].

NCT numberPhaseEnrollmentStudy start/completionLocation
Study of CS-3150 in patients with severe hypertension
NCT02808026III20June 2016/February 2017Japan
Study of CS-3150 in hypertensive patients with type 2 diabetes and albuminuria
NCT02807974III51June 2016/March 2017Japan
Study of CS-3150 in combination with ARB or ACE inhibitor in hypertensive patients with moderate renal impairment
NCT02807987III58June 2016/May 2017Japan
Long-term study of CS-3150 as monotherapy or in combination with other antihypertensive drug in Japanese patients with essential hypertension
NCT02722265III368March 2016/July, 2017Japan
Study of CS-3150 in patients with essential hypertension
III1001September 2016/July, 2017Japan

Table 3.

Esaxerenone (CS-3150) phase III clinical trials [72].


4. Structural determinants for nonsteroidal MR antagonists binding to MR LBD

To the best of our knowledge, to date 12 X-ray crystal structures of nonsteroidal ligands bound to MR LBD have been solved. Nine of these reported structures correspond to MR antagonists within the benzoxazinone moiety derivatives class (Figures 6A and 7A) (PDB IDs: compound 15, 1.82 Å 5MWP [50]; 19, 1.35 Å 3VHV [28]; 20, 2.05 Å 2WFF [29]; 21, 1.40 Å 3WFG [29]; 22, 1.10 Å 4PF3 [73]; 23, 2.5 Å 5HCV [40]; 24, 1.54 Å 6GEV [30]; 25, 1.8 Å 6GG8 [30]; and 26, 1.71 Å 6GGG [30]), whereas the remaining three correspond to a sulfonamide aryl moiety (PDB IDs: 27, 1.86 Å 5L7E; 28, 2.01 Å 5L7G; and 29, 2.12 Å 5L7H) (Figure 8A) [36].

Figure 6.

2D and 3D structures of MR benzoxazine-3-one-based antagonist complexes. (A) 2D molecular structures. (B) Superimposition of the X-ray crystal structures of MR LBD in complex with aldosterone (in orange) and compound 19 (in yellow) (left) and compounds 19 (in yellow), 20 (in red), 21 (in pink), 22 (in blue), and 23 (in cyan) (right) [75]. The hydrogen bonds and water molecules are depicted as yellow dashed lines and red spheres, respectively. IC50 from competitive binding assays.

Figure 7.

2D and 3D structures of AstraZeneca benzoxazine-3-one-based antagonist complexes. (A) 2D molecular structures. (B) Superimposition of the X-ray crystal structures of MR LBD bound to compounds 15 (in cyan), 24 (in red), and 25 (in light yellow) on the left and 15 (in cyan), 24 (in red), 25 (in light yellow), and 26 (in purple) on the right [30, 50]. The hydrogen bonds and water molecules are depicted as yellow dashed lines and red spheres, respectively. Ki from competitive binding assays.

Figure 8.

2D and 3D structures of MR sulfonamide aryl-based antagonist complexes. (A) 2D molecular structures. Superimposition of the X-ray crystal structures of MR LBD in complex with (B) compounds 27 (in orange), 28 (in magenta), and 29 (in yellow), (C) compounds 27 and 28, and (D) compounds 27 and 29 [75]. The hydrogen bonds and water molecules are depicted as yellow dashed lines and red spheres, respectively. IC50 from human MR reporter gene assays.

The X-ray crystal structure of MRC808S/S810L-LBD double mutant in complex with compound 19 first revealed the binding mode of benzoxazine-3-one derivatives. The NH group and the carbonyl oxygen of this moiety form hydrogen bonds to Asn770. In addition, the nitrogen atoms of the triazole scaffold establish hydrogen bonds to residue Gln776 and through a water molecule to Arg817 (Figure 6B). Similarly, aldosterone, the main MR hormone, is also engaged in hydrogen bonding with both Gln776 and Arg817 through its C3-ketone moiety, as well as with Asn770 through its C21-hydroxyl group (Figure 6) [74].

On the other hand, compound 20, which was reported later [29], also forms hydrogen bonds to Asn770 through the NH group and the carbonyl oxygen of benzoxazine as described for compound 19. In addition, compound 20 forms a new hydrogen bond to Thr945 through the carbonyl oxygen of the benzoxazine-3-one moiety (Figure 6B). The carbonyl oxygen in the dihydrofuran-2-one scaffold establishes hydrogen bonds to residues Arg817 and Gln776 through a water molecule. Overall, compound 20 binds to MR LBD in a similar way as compound 19. Based on these structural considerations, compound 21, a dihydrofuran-2-one derivative, was subsequently developed. As expected, the binding mode of compound 21 was similar to that of compounds 19 and 20 (Figure 6B).

Later, compound 22, a benzoxazine-3-one derivative with an azole central ring as core scaffold, was developed [73]. This molecule is a highly potent MR antagonist and also shows remarkable selectivity over other steroid hormone receptors. In addition, it exhibits good PK profile and very low partial agonistic activity [3]. The azole central ring of compound 22 was selected to avoid the formation of water-mediated hydrogen bonding networks, which is known to contribute to partial agonistic activity of some previously reported benzoxazine-3-one derivatives [29, 73]. As expected, the binding mode of compound 22 is similar to that of compounds 19–21, as observed by the solution of the X-ray crystal structure of its complex with MR LBD (PDB ID: 4PF3) (Figure 6B). The NH group and the carbonyl oxygen of the benzoxazine-3-one moiety form hydrogen bonds to Asn770 and Thr945, and the 4-fluorobenzene ring occupies the α-face hydrophobic pocket. The ligand 2,2-difluoropropyl-3-hydroxy moiety points out toward the residues Gln776 and Arg817. Its hydroxyl group directly forms a hydrogen bond to Gln776. The two fluorine atoms do not form any specific hydrogen bonding interactions suggesting that the major contribution of these fluorine atoms to the binding is hydrophobic.

In 2016, Vitae Pharmaceuticals developed compound 23, a benzoxazine-3-one derivative with a tricyclic scaffold. The X-ray crystal structure of compound 23 in complex with MR LBD showed again a binding mode similar to compounds 1922. Similarly, the benzoxazinone moiety is engaged in three hydrogen bonds, two with Asn770, through its NH and CO groups, and another one with Thr945 through its carbonyl oxygen (Figure 6B). The tricyclic structure does not engage in any hydrogen bonding with MR LBD [40].

Recently, compound 15 (AZD9977) has been identified as a novel and selective benzoxazine-3-one-based partial MR antagonist [50]. The X-ray crystal structure of compound 15 in complex with MRC808S/C910S-LBD double mutant revealed the molecular determinants of its high affinity and selectivity for MR (5MWP). Likewise, compound 15 benzoxamide moiety is also involved in hydrogen bonds with Asn770 and Thr945, whereas compound 15’s amide extension forms hydrogen bonds with Gln776, Arg817, and Ser810 (Figure 6B). An ordered water molecule is also found in the ligand-binding pocket, but it does not seem to mediate hydrogen binding between this compound and MR LBD. The 3,4-dihydro-2H-1,4-benzoxazine oxygen interacts through hydrogen bonding with Ser811. Within the steroid receptor family, Ser811 is unique to MR, which might contribute to the selectivity of compound 15. The identification of 15 was guided by structure-based design, and in this process three X-ray structures were solved, namely, those of MR LBD bound to derivatives 24, 25, and 26. As it is shown in Figure 7, the binding mode of these compounds is rather similar. However, as expected, derivative 24 is not able to interact with Gln776 or Arg817. On the other hand, the isobutyl substituent of 26 causes a rearrangement resulting in an extension of helix H7 and a reposition of helix H6 [30].

Regarding the sulfonamide aryl-based nonsteroidal MR antagonists, in 2017, Nordqvist et al. solved the first X-ray crystal structure of this scaffold-containing derivatives through hit compound 27 in complex with MR LBD (PDB ID: 5L7E) [36]. The 3D structure revealed that the isoxazole is located close to residues Gln776 and Arg817 (Figure 8). On the other side of the ligand-binding pocket, compound 27’s sulfonamide NH also interacts directly with Asn770 through hydrogen bonding. One of the sulfonamide oxygen atoms interacts with both Asn770 and Thr945 through water-mediated hydrogen bond. Interestingly, compound 27 folds back upon itself, pivoting on the sulfonamide motif, to form an intramolecular packing interaction between the two phenyl moieties acquiring a U-shaped binding mode. Following the superimposition of its X-ray crystal structure and that of compound 21 (3WFG), it was reasoned to expand the ligand from the isoxazole 5-methyl substituent toward the area around Met852 which is occupied by a phenyl ring of compound 21. Thus, compound 28 was developed with increased binding affinity toward MR and selectivity over PR and GR. The X-ray crystal structure of MR LBD and compound 28 complex (5L7G) verified that the proposed isoxazole orientation of hit compound 27 was retained and the side chain of Met852 moved to accommodate the 2,3-difluorophenoxymethyl moiety (Figure 8C). Afterwards, a deeper analysis of ligand binding modes inspired the design of compound 29, the first potent macrocyclic oxosteroid receptor antagonist. Despite the conformation constraints imposed by the macrocyclization, the X-ray crystal structure of the complex between MR LBD and compound 29 (5L7H [36]) disclosed that the ligand interactions to the receptor stayed the same as those exhibited by compounds 27 and 28 (Figure 8D). It is worth noting that the water molecule mediating hydrogen bond between compounds 2729 and Ans770 and Thr945 is displaced by the benzoxazine scaffold in compounds 15 and 1925 (Figures 6 and 7). For these latter compounds, the benzoxazine scaffold forms a bidentate hydrogen bonding with Asn770 and an additional hydrogen bond with Thr945.


5. Conclusions

Since 1959 in which the steroid MR antagonist spironolactone was introduced in the market [42], continuous research has been carried out in attempting to overcome the undesired side effects of this drug. Eplerenone, a second-generation MR antagonist, although more selective for MR, still increases the incidence of hyperkalemia. For this reason, the research was turned toward a third generation of compounds, comprising nonsteroidal antagonists within different chemotypes, which show in general lower side effects. Several examples of this third generation have entered clinical trials as compiled in this review. However, in spite of the last decades of advances, there are still important questions that need further research. Thus, for example, the structural requirements needed for ligands to discriminate the recruitment of different co-regulators and, hence, to fine-tune the transcription of selected genes are still poorly understood. Undoubtedly, a larger body of knowledge in this field will contribute significantly to the future development of novel MR antagonists with improved properties.



This publication is based upon work from the EU COST Action ADMIRE BM1301 in Aldosterone and Mineralocorticoid Receptor (MR) Physiology and Pathophysiology ( Also supported by grants from Ministerio de Economia y Competitividad (MINECO, Spain; grant SAF2015-66275-C2-2-R and BFU2016-78374-R), CUNY (CCRG-1532), and the Hostos Office of Academic Affairs, US National Institute of Health (NIGMS) SC2GM111231.


  1. 1. Rossier BC, Baker ME, Studer RA. Epithelial sodium transport and its control by aldosterone: The story of our internal environment revisited. Physiological Reviews. 2015;95:297-340
  2. 2. Chapman K, Holmes M, Seckl J. 11beta-hydroxysteroid dehydrogenases: Intracellular gate-keepers of tissue glucocorticoid action. Physiological Reviews. 2013;93:1139-1206
  3. 3. Gomez-Sanchez E, Gomez-Sanchez CE. The multifaceted mineralocorticoid receptor. Comprehensive Physiology. 2014;4:965-994
  4. 4. Gomez-Sanchez EP. Third-generation mineralocorticoid receptor antagonists: Why do we need a fourth? Journal of Cardiovascular Pharmacology. 2016;67:26-38
  5. 5. Jaisser F, Farman N. Emerging roles of the mineralocorticoid receptor in pathology: Toward new paradigms in clinical pharmacology. Pharmacological Reviews. 2016;68:49-75
  6. 6. Young MJ, Rickard AJ. Mechanisms of mineralocorticoid salt-induced hypertension and cardiac fibrosis. Molecular and Cellular Endocrinology. 2012;350:248-255
  7. 7. Herrada AA et al. Aldosterone as a modulator of immunity: Implications in the organ damage. Journal of Hypertension. 2011;29:1684-1692
  8. 8. Queisser N, Schupp N. Aldosterone, oxidative stress, and NF-kappaB activation in hypertension-related cardiovascular and renal diseases. Free Radical Biology & Medicine. 2012;53:314-327
  9. 9. Bauersachs J, Jaisser F, Toto R. Mineralocorticoid receptor activation and mineralocorticoid receptor antagonist treatment in cardiac and renal diseases. Hypertension. 2015;65:257-263
  10. 10. Kolkhof P et al. Steroidal and novel non-steroidal mineralocorticoid receptor antagonists in heart failure and cardiorenal diseases: Comparison at bench and bedside. Handbook of Experimental Pharmacology. 2017;243:271-305
  11. 11. Infante M, Armani A, Mammi C, Fabbri A, Caprio M. Impact of adrenal steroids on regulation of adipose tissue. Comprehensive Physiology. 2017;7:1425-1447
  12. 12. Daruich A et al. Central serous chorioretinopathy: Recent findings and new physiopathology hypothesis. Progress in Retinal and Eye Research. 2015;48:82-118
  13. 13. Brown R, Quirk J, Kirkpatrick P. Eplerenone. Nature Reviews. Drug Discovery. 2003;2:177-178
  14. 14. Alvarez de la Rosa D, Navarro-Gonzalez JF, Giraldez T. ENaC modulators and renal disease. Current Molecular Pharmacology. 2013;6:35-43
  15. 15. Roscioni SS, de Zeeuw D, Bakker SJ, Lambers Heerspink HJ. Management of hyperkalaemia consequent to mineralocorticoid-receptor antagonist therapy. Nature Reviews. Nephrology. 2012;8:691-699
  16. 16. Martin-Martinez M et al. Modulating mineralocorticoid receptor with non-steroidal antagonists. New opportunities for the development of potent and selective ligands without off-target side effects. Journal of Medicinal Chemistry. 2017;60:2629-2650
  17. 17. Arhancet GB et al. Stereochemical requirements for the mineralocorticoid receptor antagonist activity of dihydropyridines. Journal of Medicinal Chemistry. 2010;53:4300-4304
  18. 18. Bärfacker L et al. Discovery of BAY 94-8862: A nonsteroidal antagonist of the mineralocorticoid receptor for the treatment of cardiorenal diseases. ChemMedChem. 2012;7:1385-1403
  19. 19. Arhancet GB et al. Discovery of novel cyanodihydropyridines as potent mineralocorticoid receptor antagonists. Journal of Medicinal Chemistry. 2010;53:5970-5978
  20. 20. Fagart J et al. A new mode of mineralocorticoid receptor antagonism by a potent and selective nonsteroidal molecule. The Journal of Biological Chemistry. 2010;285:29932-29940
  21. 21. Fagart J et al. Antagonism in the human mineralocorticoid receptor. The EMBO Journal. 1998;17:3317-3325
  22. 22. Brandish P, Fraley E, Mark E, Hershey JC, Steen JT. Mineralocorticoid receptor modulators. 2009. WO2009/078934A1
  23. 23. Arai K et al. Pharmacological profile of CS-3150, a novel, highly potent and selective non-steroidal mineralocorticoid receptor antagonist. European Journal of Pharmacology. 2015;761:226-234
  24. 24. Casimiro-Garcia A et al. Identification of (R)-6-(1-(4-Cyano-3-methylphenyl)-5-cyclopentyl-4,5-dihydro-1H-pyrazol-3-yl)-2-methoxynicotinic acid, a highly potent and selective nonsteroidal mineralocorticoid receptor antagonist. Journal of Medicinal Chemistry. 2014;57:4273-4288
  25. 25. Meyers MJ et al. Discovery of (3S,3aR)-2-(3-Chloro-4-cyanophenyl)-3-cyclopentyl-3,3a,4,5-tetrahydro-2H-benzo[g]indazole-7-carboxylic acid (PF-3882845), an orally efficacious mineralocorticoid receptor (MR) antagonist for hypertension and nephropathy. Journal of Medicinal Chemistry. 2010;53:5979-6002
  26. 26. Cox JM et al. Mineralocorticoid receptor antagonists: Identification of heterocyclic amide replacements in the oxazolidinedione series. Bioorganic & Medicinal Chemistry Letters. 2014;24:1681-1684
  27. 27. Michellys PY, Pei W, Petrassi HM, Richmond W. Compounds and compositions as modulators of steroid hormone nuclear receptors. 2006. WO2006/015259
  28. 28. Hasui T et al. Identification of benzoxazin-3-one derivatives as novel, potent, and selective nonsteroidal mineralocorticoid receptor antagonists. Journal of Medicinal Chemistry. 2011;54:8616-8631
  29. 29. Hasui T et al. Design, synthesis, and structure–activity relationships of dihydrofuran-2-one and dihydropyrrol-2-one derivatives as novel benzoxazin-3-one-based mineralocorticoid receptor antagonists. Bioorganic & Medicinal Chemistry. 2013;21:5983-5994
  30. 30. Granberg KL et al. Identification of mineralocorticoid receptor modulators with low impact on electrolyte homeostasis but maintained organ protection. Journal of Medicinal Chemistry. 2019;62:1385-1406
  31. 31. Neel DA et al. 3,3-Bisaryloxindoles as mineralocorticoid receptor antagonists. Bioorganic & Medicinal Chemistry Letters. 2005;15:2553-2557
  32. 32. Bell MG et al. (S)-N-{3-[1-Cyclopropyl-1-(2,4-difluoro-phenyl)-ethyl]-1H-indol-7-yl}-methanesulfonamide: A potent, nonsteroidal, functional antagonist of the mineralocorticoid receptor. Journal of Medicinal Chemistry. 2007;50:6443-6445
  33. 33. Cernak TA, Dykstra KD. Mineralocorticoid receptor antagonists. 2014. WO2014/014794A2
  34. 34. Katayama S, Hori S, Hasegawa F, Suzuki K. Biaryl amide derivative or pharmaceutically acceptable salt thereof. 2013. US2013/116227A1
  35. 35. Boyer S, Guo X, Wu D, Wu F. Pyridyl ureas as mineralocorticoid receptor antagonists. 2012. WO2012/064631A1
  36. 36. Nordqvist A et al. Structure-based drug design of mineralocorticoid receptor antagonists to explore oxosteroid receptor selectivity. ChemMedChem. 2017;12:50-65
  37. 37. Kowala MC. Combination therapy for resistant hypertension. 2015. WO2015/130568
  38. 38. [Accessed: July 27, 2018]
  39. 39. [Accessed: July 27, 2018]
  40. 40. Lotesta SD et al. Identification of spirooxindole and dibenzoxazepine motifs as potent mineralocorticoid receptor antagonists. Bioorganic and Medicinal Chemistry. 2016;24:1384-1391
  41. 41. Kolkhof P, Nowack C, Eitner F. Nonsteroidal antagonists of the mineralocorticoid receptor. Current Opinion in Nephrology and Hypertension. 2015;24:417-424
  42. 42. The Practice of Medicinal Chemistry. 3rd ed. Academic Press; 2008
  43. 43. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  44. 44. Wang EB, Chaudhary A, Waterhouse TH, Dickinson GL. Population pharmacokinetics of LY2623091 in patients with hypertension and chronic kidney disease. Journal of Clinical Pharmacology. 2017;57:739-746
  45. 45. Dickinson GL, Phillips DL, Posada MM, Chaudhary A, Hall SD. Physiologically based pharmacokinetic modeling to understand the observed drug-drug interaction of LY2623091 with CYP3A inhibitors itraconazole and diltiazem. International Journal of Pharmacokinetics. 2017;2:233-245
  46. 46. Clinical Trial Information. Available from: [Accessed: July 27, 2018]
  47. 47. [Accessed: July 27, 2018]
  48. 48. [Accessed: July 27, 2018]
  49. 49. [Accessed: July 27, 2018]
  50. 50. Bamberg K et al. Preclinical pharmacology of AZD9977: A novel mineralocorticoid receptor modulator separating organ protection from effects on electrolyte excretion. PLoS One. 2018;13:e0193380
  51. 51. Erlandsson F et al. Clinical safety, tolerability, pharmacokinetics and effects on urinary electrolyte excretion of AZD9977, a novel, selective mineralocorticoid receptor modulator. British Journal of Clinical Pharmacology. 2018;84:1486-1493
  52. 52. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  53. 53. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  54. 54. IIijima TY, Akatsuka H, Kawaguchi T. Benzoxazines and related nitrogen-containing heterobicyclic compounds useful as mineralocorticoid receptor modulating agents. 2007. WO2007/089034
  55. 55. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  56. 56. Amazit L et al. Finerenone impedes aldosterone-dependent nuclear import of the mineralocorticoid receptor and prevents genomic recruitment of steroid receptor coactivator-1. The Journal of Biological Chemistry. 2015;290:21876-21889
  57. 57. Grune J et al. Selective mineralocorticoid receptor cofactor modulation as molecular basis for finerenone's antifibrotic activity. Hypertension. 2018;71:599-608
  58. 58. Kolkhof P et al. Finerenone, a novel selective nonsteroidal mineralocorticoid receptor antagonist protects from rat cardiorenal injury. Journal of Cardiovascular Pharmacology. 2014;64:69-78
  59. 59. Pitt B et al. Rationale and design of ARTS: A randomized, double-blind study of BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease. European Journal of Heart Failure. 2012;14:668-675
  60. 60. Pitt B et al. Safety and tolerability of the novel non-steroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: A randomized, double-blind trial. European Heart Journal. 2013;34:2453-2463
  61. 61. Haller H, Bertram A, Stahl K, Menne J. Finerenone: A new mineralocorticoid receptor antagonist without hyperkalemia: An opportunity in patients with CKD? Current Hypertension Reports. 2016;18:1-9
  62. 62. Heinig R, Kimmeskamp-Kirschbaum N, Halabi A, Lentini S. Pharmacokinetics of the novel nonsteroidal mineralocorticoid receptor antagonist finerenone (BAY 94-8862) in individuals with renal impairment. Clinical Pharmacology in Drug Development. 2016;5:488-501
  63. 63. Bakris GL et al. Effect of finerenone on albuminuria in patients with diabetic nephropathy: A randomized clinical trial. JAMA, the Journal of the American Medical Association. 2015;314:884-894
  64. 64. Bramlage P et al. Non-steroidal mineralocorticoid receptor antagonism for the treatment of cardiovascular and renal disease. European Journal of Heart Failure. 2016;18:28-37
  65. 65. Filippatos G et al. A randomized controlled study of finerenone vs. eplerenone in patients with worsening chronic heart failure and diabetes mellitus and/or chronic kidney disease. European Heart Journal. 2016;37:2105-2114
  66. 66. Lachaux M et al. Short- and long-term administration of the non-steroidal mineralocorticoid receptor antagonist finerenone opposes metabolic syndrome-related cardio-renal dysfunction. Diabetes, Obesity & Metabolism. 2018. p. 1-9
  67. 67. Bender SB et al. Mineralocorticoid receptor antagonism treats obesity-associated cardiac diastolic dysfunction. Hypertension. 2015;65:1082-1088
  68. 68. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  69. 69. Arai K, Tsuruoka H, Homma T. CS-3150, a novel non-steroidal mineralocorticoid receptor antagonist, prevents hypertension and cardiorenal injury in Dahl salt-sensitive hypertensive rats. European Journal of Pharmacology. 2015;769:266-273
  70. 70. Arai K, Morikawa Y, Ubukata N, Tsuruoka H, Homma T. CS-3150, a novel nonsteroidal mineralocorticoid receptor antagonist, shows preventive and therapeutic effects on renal injury in deoxycorticosterone acetate/salt-induced hypertensive rats. The Journal of Pharmacology and Experimental Therapeutics. 2016;358:548-557
  71. 71. [Accessed: July 27, 2018]
  72. 72. Clinical Trials Information. Available from: [Accessed: July 27, 2018]
  73. 73. Hasui T et al. Discovery of 6-[5-(4-fluorophenyl)-3-methyl-pyrazol-4-yl]-benzoxazin-3-one derivatives as novel selective nonsteroidal mineralocorticoid receptor antagonists. Bioorganic & Medicinal Chemistry. 2014;22:5428-5445
  74. 74. Bledsoe RK et al. A ligand-mediated hydrogen bond network required for the activation of the mineralocorticoid receptor. The Journal of Biological Chemistry. 2005;280:31283-31293
  75. 75. Pymol Molecular Graphics System, Version 1.7 Schrödinger, LLC

Written By

Felipe L. Pérez-Gordillo, Maria Jesús Pérez de Vega, Guillermo Gerona-Navarro, Yoel Rodríguez, Diego Alvarez de la Rosa, Rosario González-Muñiz and Mercedes Martín-Martínez

Reviewed: 05 July 2019 Published: 25 September 2019