Aldosterone Synthase Inhibitors for Resistant Hypertension: Pharmacological Insights – A Systematic Review

Cicero, AFG, Tocci, G, Avagimyan, A, Penson, P ORCID: 0000-0001-6763-1489, Nardoianni, G, Perone, F, Borghi, C and Fogacci, F ORCID: 0000-0001-7853-0042 (2025) Aldosterone Synthase Inhibitors for Resistant Hypertension: Pharmacological Insights – A Systematic Review. Drugs. pp. 1-25. ISSN 0012-6667

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Abstract

Background: Resistant hypertension (RHT) is a challenging clinical condition characterized by persistently elevated blood pressure despite adherence to lifestyle modifications and the use of at least three antihypertensive agents, including a high-dose diuretic. RHT is a heterogeneous condition, influenced by multiple pathophysiological mechanisms such as sodium retention, sympathetic overactivity, and vascular dysfunction. Among these, hyperaldosteronism plays a pivotal role in a subset of patients. Methods: This systematic review examines in depth the pharmacokinetic properties of aldosterone synthase inhibitors (ASIs), with a focus on their therapeutic potential in patients with RHT. A comprehensive literature search was conducted to identify clinical trials and pharmacological studies investigating ASIs, including baxdrostat, dexfadrostat, lorundrostat, LY3045697, and osilodrostat (LCI699). Results: ASIs have shown compelling efficacy in lowering both office-based and 24-h ambulatory blood pressure, particularly in patients with elevated aldosterone levels. These findings underscore the critical role of aldosterone-mediated mechanisms in the pathophysiology of RHT. The inhibitors differ substantially in their metabolic pathways, selectivity profiles, and pharmacokinetic characteristics. Conclusions: Emerging data support the potential of ASIs as a therapeutic option for RHT, particularly when treatment is individualized based on renal function, dietary sodium intake, and comorbidities. Personalized treatment strategies may enhance efficacy, improve tolerability, and support durable blood pressure control in this difficult-to-treat population. Registration: PROSPERO identifier number CRD42024522918

Item Type:	Article
Uncontrolled Keywords:	32 Biomedical and Clinical Sciences; 3202 Clinical Sciences; Hypertension; Cardiovascular; 6.1 Pharmaceuticals; Cardiovascular; 1115 Pharmacology and Pharmaceutical Sciences; Pharmacology & Pharmacy; 3202 Clinical sciences; 3214 Pharmacology and pharmaceutical sciences
Subjects:	R Medicine > RS Pharmacy and materia medica
Divisions:	Pharmacy and Biomolecular Sciences
Publisher:	Springer Science and Business Media LLC
Date of acceptance:	12 August 2025
Date of first compliant Open Access:	2 October 2025
Date Deposited:	02 Oct 2025 15:26
Last Modified:	02 Oct 2025 15:45
DOI or ID number:	10.1007/s40265-025-02229-2
URI:	https://researchonline.ljmu.ac.uk/id/eprint/27253

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