Professor, Ellison what is the future in the use of diuretics to treat hypertension and heart failure? You are a renowned expert on the intersection of these two very complex diseases. So, what's in the next 5 to 10 years? Well, I think the first thing is that people have wanted for 50 years or more to get away from using diuretics. And we're still using diuretics because they are remarkably effective. Diuretics were utilized in ancient times. And, in fact, Paracelsus, the so-called Father of pharmacology, used mercury as a diuretic to treat edema back many hundreds of years ago. So, I don't think we're going to get away from using diuretic drugs to treat these conditions. And I'm not sure we should want to get away, I think we're going to find new approaches to diuretics and maybe new ways to use them. So, the first thing I comment on is this idea that this new drug Finerenone, which is a nonsteroidal mineralocorticoid receptor blocker. So, all the other mineralocorticoid receptor antagonists are steroid antagonists. This is a non-steroidal drug. And there is some hint that it may have a different action. So, we think that aldosterone acts all over the body and has many effects that affect the blood vessels. It clearly affects the brain, it also affects the kidney, the side effects are mostly in the kidney. And it's mostly this hyperkalemia that we worry about. Dr. David Ellison, MD.: And so, a lot of patients who would otherwise be candidates for using mineralocorticoid receptor blockers can't use them because they develop hyperkalemia. Dr. David Ellison, MD.: And so, we can either give them these drugs that bind potassium in the gut. But that's kind of a workaround that's not really addressing the fundamental problem. So, I think there is some possibility that Finerenone may have different properties that maybe have more of the good and not as much of the bad and if Finerenone doesn't, maybe a subsequent drug will be able to, for example, block the mineralocorticoid receptors in the heart or the brain, but not cause as much hyperkalemia. So, I think figuring out how to get the good parts of diuresis, without the bad, is really important. And then the second thing is just I think there's a lot of room for using these drugs better, even though they've been used for almost 100 years. And in terms of how we approach heart failure, trying to prevent the development of acute decompensated heart failure and these patients who come into the hospital, we have to do a better job of that. And I think that there's been a debate in the cardiology literature about whether it's useful to get people off of diuretics for a while if they have heart failure. And there are some patients who you can wean off diuretics. And there's been a lot of interest in that. But it's never been demonstrated that the long-term outcomes are really better in those patients. It's been shown that it's feasible that some patients can do okay without diuretics. But most of those patients have pretty mild heart failure anyways. I do think the idea that we could find a way to keep people on diuretics without causing the adverse compensatory changes, is very attractive, and it's something we should focus on. So, in heart failure, I think we should focus on before they get to the acute decompensation and try and prevent that from happening. And that's where I think the future is.
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