COMBINATION OF FINERENONE AND A SGLT2 INHIBITOR FOR THE TREATMENT AND/OR PREVENTION OF CARDIOVASCULAR AND/OR RENAL DISEASES

Abstract

The present invention relates to pharmaceutical compositions and combinations comprising finerenone or a hydrate, solvate or pharmaceutically acceptable salt thereof or a polymorph thereof and a SGLT2 inhibitor, or a hydrate, solvate or pharmaceutically acceptable salt thereof or a polymorph thereof. The combination can be used for the treatment and/or prevention of cardiovascular and/or renal diseases in humans and other mammals.

Claims

1. A combination comprising finerenone or a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof, and a SGLT2 inhibitor, or a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof.

2. The combination according to claim 1, wherein the SGLT2 inhibitor is selected from the group consisting of canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin, remogliflozin, sergliflozin and tofogliflozin.

3. The combination according to claim 1, wherein the SGLT2 inhibitor is selected from the group consisting of canagliflozin, dapagliflozin, and empagliflozin.

4. The combination according to claim 1, wherein the combination is selected from the group consisting of or is part of a fixed combination, a single dosage form, two separate dosage forms, a combination pack, a kit-of-parts or a non-fixed combination.

5. The combination according to claim 1, wherein the combination comprises the components: a. one dosage form comprising finerenone or a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof, and b. one dosage form comprising a SGLT2 inhibitor a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof.

6. The combination according to claim 5, wherein the components a. and b. are administered separately, sequentially, simultaneously, concurrently or chronologically staggered.

7. The combination according to claim 1, wherein the combination is a single dosage form.

8. The combination according to claim 1, wherein the combination comprises finerenone or a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof, in an amount of 0.25 to 80 mg.

9. The combination according to claim 1, wherein the combination comprises finerenone or a hydrate, solvate, pharmaceutically acceptable salt thereof, or a polymorph thereof and wherein the SGLT2 inhibitor is selected from empagliflozin or an anhydrate, a hydrate thereof, solvate thereof, pharmaceutically acceptable salt thereof, a prodrug thereof or a polymorph thereof in an amount of 0.5 to 30 mg, dapagliflozin or an anhydrate, a hydrate thereof, solvate thereof, pharmaceutically acceptable salt thereof, a prodrug thereof or a polymorph thereof in an amount of 0.5 to 20 mg, and canagliflozin or an anhydrate, a hydrate thereof, solvate thereof, pharmaceutically acceptable salt thereof, a prodrug thereof or a polymorph thereof in an amount of 0.5 mg to 300 mg.

10. The combination according to claim 1 for once daily application.

11. A medicament comprising the combination according to claim 1 and an inert, nontoxic, pharmaceutically suitable excipient.

12. The combination according to claim 11 for use as medicament for treating and/or preventing diseases.

13. The combination according to claim 1 for use as medicament for treating and/or preventing diseases, wherein the diseases is selected from: cardiovascular disorders such as congestive heart failure, acute heart failure, chronic heart failure, worsening chronic heart failure (WCHF), hospitalization for heart failure, heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF) or heart failure with reduced ejection fraction (HFrEF); renal and cardiorenal disorders such as chronic kidney disease (CKD), non-diabetic chronic kidney disease (ndCKD), diabetic kidney disease (DKD), hypertensive kidney disease, cardiorenal syndrome, nephrotic syndrome, hepatorenal syndrome, renal hypoperfusion, intradialytic hypotension, obstructive uropathy, glomerulopathies, IgA nephropathy, glomerulonephritis, glomerulosclerosis, tubulointerstitial diseases, nephropathic diseases such as primary and congenital kidney disease, nephritis, Alport syndrome, kidney inflammation, immunological kidney diseases, kidney transplant rejection, immune complex-induced kidney diseases, nephropathy induced by toxic substances, contrast medium-induced nephropathy; minimal change glomerulonephritis (lipoid), focal segmental glomerulosclerosis (FSGS), amyloidosis, renal cysts, hypertensive nephrosclerosis and nephrotic syndrome (which can be characterized diagnostically, for example, by abnormally reduced creatinine and/or water excretion, abnormally increased blood concentrations of urea, nitrogen, potassium and/or creatinine, altered urine osmolarity or urine volume, increased microalbuminuria, macroalbuminuria, lesions of glomeruli and arterioles, tubular dilatation, hyperphosphataemia and/or the need for dialysis), uraemia, anaemia, electrolyte disturbances (for example hyperkalaemia, hyponatraemia, disturbances in bone and carbohydrate metabolism, polycystic kidney disease (PCKD) and of the syndrome of inadequate ADH secretion (SIADH); edema, pulmonary edema, cerebral edema, renal edema and heart failure-related edema; cirrhosis; NASH (non-alcoholic steatohepatitis); arterial hypertension, resistant hypertension, pulmonary hypertension, essential hypertension; cardiovascular disorders such as hypertension, left ventricular dysfunction, hypertrophic cardiomyopathy, diabetic cardiomyopathy, supraventricular arrythmias, ventricular arrythmias, atrial fibrillation, atrial flutter, cardiovascular disorders such as stable angina pectoris, unstable angina pectoris, myocardial infarction and sequelae thereof, aneurysms, detrimental vascular remodelling, atherosclerosis, atrial fibrillation, stroke; shock such as cardiogenic shock, septic shock and anaphylactic shock; hypertensive kidney disease, peripheral arterial disease (PAD) including claudication and including critical limb ischemia, coronary microvascular dysfunction (CMD) including CMD type 1-4, primary and secondary Raynaud's phenomenon, microcirculation disturbances, peripheral and autonomic neuropathies, diabetic microangiopathies, diabetic retinopathy, diabetic limb ulcers, gangrene, CREST syndrome, erythematous disorders, rheumatic diseases, for promoting wound healing, inflammatory diseases, asthmatic diseases, chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), acute lung injury (ALI), alpha-1-antitrypsin deficiency (AATD), pulmonary fibrosis, pulmonary emphysema (for example smoking-induced pulmonary emphysema) and cystic fibrosis (CF); lung disorders and cardiopulmonary disorders such as pulmonary hypertension, disorders of the central nervous system; fibrotic disorders and other disease manifestations (for example end organ damage affecting brain, kidney or heart); Sleep apnea; Obesity; Coronary Artery Disease (CAD); Acute Kidney Injury (AKI); Chronic kidney disease after Acute Kidney Injury following Major surgery (AKIM); multiple insults such as ischemia-reperfusion injury, radiocontrast administration, cardiopulmonary bypass surgery, shock and sepsis.

14. The combination according to claim 13, wherein the diseases is selected from chronic kidney disease (CKD), hypertensive kidney disease, diabetic kidney disease (DKD), non-diabetic chronic kidney disease (ndCKD), chronic kidney disease in patients with type-1-diabetes, chronic kidney disease in patients with type-2-diabetes, diabetic retinopathy, diabetic retinopathy in patients with type-1-diabetes, diabetic retinopathy in patients with type-2-diabetes, worsening chronic heart failure (WCHF), heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), heart failure with reduced ejection fraction (HFrEF).

15. A method for preventing and/or treating a cardiovascular and/or renal disease in a subject in need thereof comprising administering to the subject a therapeutically effective amount of the combination according to claim 1.

Description

DESCRIPTION OF THE FIGURES

[0515] FIG. 1a: Influence of the SGLT2 inhibitor empagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on urinary volume of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=6-8 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg empagliflozin (group B), 3 mg/kg empagliflozin (group C), 10 mg/kg empagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg empagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg empagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg empagliflozin+1 mg/kg finerenone combination (group H).

[0516] FIG. 1b: Influence of the SGLT2 inhibitor empagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on the urinary glucose concentration of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=6-8 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg empagliflozin (group B), 3 mg/kg empagliflozin (group C), 10 mg/kg empagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg empagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg empagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg empagliflozin+1 mg/kg finerenone combination (group H).

[0517] FIG. 1c: Influence of the SGLT2 inhibitor empagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on the urinary potassium concentration of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=6-8 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg empagliflozin (group B), 3 mg/kg empagliflozin (group C), 10 mg/kg empagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg empagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg empagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg empagliflozin+1 mg/kg finerenone combination (group H).

[0518] FIG. 1d: Influence of the SGLT2 inhibitor empagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on the urinary sodium concentration of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=6-8 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg empagliflozin (group B), 3 mg/kg empagliflozin (group C), 10 mg/kg empagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg empagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg empagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg empagliflozin+1 mg/kg finerenone combination (group H).

[0519] FIG. 2a: Influence of two dosages of the SGLT2 inhibitor empagliflozin (groups B and C), two dosages of the MR antagonist finerenone (groups D and E), and the combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone (group F), respectively, on urinary volume of awake ZDF rats chronically treated with groups A to F, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours in metabolic cages. n=14-16 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 3 mg/kg empagliflozin (group B), 10 mg/kg empagliflozin (group C), 3 mg/kg finerenone (group D), 10 mg/kg finerenone (group E), 3 mg/kg empagliflozin+3 mg/kg finerenone combination (group F).

[0520] FIG. 2b: Influence of two dosages of the SGLT2 inhibitor empagliflozin (groups B and C), two dosages of the MR antagonist finerenone (groups D and E), and the combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone (group F), respectively, on the urinary glucose concentration of awake ZDF rats chronically treated with groups A to F, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours in metabolic cages. n=14-16 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 3 mg/kg empagliflozin (group B), 10 mg/kg empagliflozin (group C), 3 mg/kg finerenone (group D), 10 mg/kg finerenone (group E), 3 mg/kg empagliflozin+3 mg/kg finerenone combination (group F).

[0521] FIG. 2c: Influence of two dosages of the SGLT2 inhibitor empagliflozin (groups B and C), two dosages of the MR antagonist finerenone (groups D and E), and the combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone (group F), respectively, on the urinary potassium concentration of awake ZDF rats chronically treated with groups A to F, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours in metabolic cages. n=14-16 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 3 mg/kg empagliflozin (group B), 10 mg/kg empagliflozin (group C), 3 mg/kg finerenone (group D), 10 mg/kg finerenone (group E), 3 mg/kg empagliflozin+3 mg/kg finerenone combination (group F).

[0522] FIG. 2d: Influence of two dosages of the SGLT2 inhibitor empagliflozin (groups B and C), two dosages of the MR antagonist finerenone (groups D and E), and the combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone (group F), respectively, on the urinary sodium concentration (FIG. 2d) of awake ZDF rats chronically treated with groups A to F, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours in metabolic cages. n=14-16 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 3 mg/kg empagliflozin (group B), 10 mg/kg empagliflozin (group C), 3 mg/kg finerenone (group D), 10 mg/kg finerenone (group E), 3 mg/kg empagliflozin+3 mg/kg finerenone combination (group F).

[0523] FIG. 3a: Mortality was studied in hypertensive and proteinuric L-NAME (20 mg/L) treated renin-transgenic (mRen2)27 rats.

[0524] FIG. 3b: Proteinuria was studied in hypertensive and proteinuric L-NAME (20 mg/L) treated renin-transgenic (mRen2)27 rats.

[0525] FIG. 4: Influence of the SGLT2 inhibitor canagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on (a) urinary volume (FIG. 4a), (b) the urinary glucose concentration (FIG. 4b), (c) the urinary potassium concentration (FIGS. 4c), and (d) the urinary sodium concentration (FIG. 4d), of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=9-10 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg canagliflozin (group B), 3 mg/kg canagliflozin (group C), 10 mg/kg canagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg canagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg canagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg canagliflozin+1 mg/kg finerenone combination (group H).

[0526] FIG. 5: Influence of the SGLT2 inhibitor dapagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on (a) urinary volume (FIG. 5a), (b) the urinary glucose concentration (FIG. 5b), (c) the urinary potassium concentration (FIGS. 5c), and (d) the urinary sodium concentration (FIG. 5d), of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B below, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=10 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 0.03 mg/kg dapagliflozin (group B), 0.3 mg/kg dapagliflozin (group C), 3 mg/kg dapagliflozin (group D), 1 mg/kg finerenone (group E), 0.03 mg/kg dapagliflozin+1 mg/kg finerenone combination (group F), 0.3 mg/kg dapagliflozin+1 mg/kg finerenone combination (group G), 3 mg/kg dapagliflozin+1 mg/kg finerenone combination (group H).

EXAMPLES

A—Pharmaceutical Formulation/Dosage Form

A-1-1: Tablet Comprising Finerenone (4S)-4-(4-cyano-2-methoxyphenyl)-5-ethoxy-2,8-dimethyl-1,4-dihydro-1,6-naphthyridine-3-carboxamide of the Formula (I)

[0527] A granulate solution of the compound of formula (I) in crystalline form in micronized form, hypromellose 5 cP, sodium lauryl sulfate in purified water was prepared. Microcrystalline cellulose, lactose monohydrate and croscarmellose sodium were mixed in a container or a fluidized bed granulator (premix). The premix and the granulate solution were granulated in the fluid-bed granulator. The lubricant magnesium stearate was added after the granules were dried and sieved. A ready-to-press mixture was thus produced. The ready-to-press mixture was pressed into tablets using a rotary tablet press.

[0528] A homogeneous coating suspension was made from hypromellose, talc, titanium dioxide, yellow iron oxide, red iron oxide and purified water. The coating suspension was sprayed onto the tablets in a suitable coating device.

TABLE-US-00001 TABLE 1-1 Tablets (number 1 to 7) obtained by the process described above Tablets 1 2 3 4 5 6 7 Composition [mg] [mg] [mg] [mg] [mg] [mg] [mg] Finerenone, 1.25 2.50 5.00 7.50 10.00 15.00 20.00 micronized Excipients Cellulose 73.80 72.50 69.90 67.30 64.70 62.00 59.30 microcrystalline Crosscarmellose 4.50 4.50 4.50 4.50 4.50 4.50 4.50 sodium Hypromellose 5 4.50 4.50 4.50 4.50 4.50 4.50 4.50 cP Lactose 45.00 45.00 45.00 45.00 45.00 42.50 40.00 monohydrate Magnesium 0.90 0.90 0.90 0.90 0.90 0.90 0.90 stearate Sodium 0.05 0.10 0.20 0.30 0.40 0.60 0.80 laurilsulfate Weight 130.00 130.00 130.00 130.00 130.00 130.00 130.00 (uncoated tablet) Film- Hypromellose 5 3.0336 3.0336 3.0336 3.0336 3.0336 3.0336 3.0336 coating cP Titanium 2.3196 2.3196 2.3196 2.3196 2.3196 2.3196 2.3196 dioxide Talcum 0.6072 0.6072 0.6072 0.6072 0.6072 0.6072 0.6072 Iron oxide 0.0324 0.0324 0.0324 0.0324 0.0324 0.0324 0.0324 yellow Iron oxide 0.0072 0.0072 0.0072 0.0072 0.0072 0.0072 0.0072 red Weight 6.0000 6.0000 6.0000 6.0000 6.0000 6.0000 6.0000 (film-coating) Weight 136.00 136.00 136.00 136.00 136.00 136.00 136.00 (coated tablet)

A-1-2: Tablets Comprising Finerenone (4S)-4-(4-cyano-2-methoxyphenyl)-5-ethoxy-2,8-dimethyl-1,4-dihydro-1,6-naphthyridine-3-carboxamide of the Formula (I)

[0529] A granulate suspension of the compound of formula (I) in crystalline form in micronized form, hypromellose, sodium lauryl sulfate in purified water was prepared. Microcrystalline cellulose, lactose monohydrate and croscarmellose sodium were mixed in a container or a fluidized bed granulator (premix). The premix and the granulate solution were granulated in the fluid-bed granulator. The lubricant magnesium stearate was added after the granules were dried and sieved. A ready-to-press mixture was thus produced. The ready-to-press mixture was compressed into tablets using a rotary tablet press. A homogeneous coating suspension was made from hypromellose, talc, titanium dioxide, yellow iron oxide, red iron oxide and/or black iron oxide and purified water. The coating suspension was sprayed onto the tablets in a suitable coating device. The composition of the tablets obtained by the process described are listed in table 1-2.

TABLE-US-00002 TABLE 1-2 Tablets (8 to 12 obtained) obtained by the process described above Tablets 8 9 10 11 12 Composition [mg] [mg] [mg] [mg] [mg] Finerenone 40 5 10 20 40 micronized Excipients Cellulose 110 69.9 64.7 59.3 110 microcrystalline Croscarmellose 15 4.5 4.5 4.5 15 sodium Hypromellose 5 7 4.5 4.5 4.5 7 cP Lactose 25 45 45 40 25 monohydrate Magnesium 1.4 0.9 0.9 0.9 1.4 stearate Sodium 1.6 0.2 0.4 0.8 1.6 laurilsulfate Purified water in q.s. q.s. q.s. q.s. q.s. bulk Weight 200 130 130 130 200 (uncoated tablet) Film Hypromellose 5 3.5392 3 3 3 3.5 coating cP Talc 0.7084 0.6 0.6 0.6 0.7 Titanium dioxide 2.7062 2.36 2.28 1.92 2.222 Ferric oxide 0.0378 — — 0.48 0.473 yellow Ferric oxide red 0.0084 — 0.12 — 0.105 Ferric oxide black — 0.04 — — — Purified water in q.s. q.s. q.s. q.s. q.s. bulk Weight (film 7 6 6 6 7 coating) Weight 207 136 136 136 207 (coated tablet)

[0530] As film coatings, commercially available film coatings can be used for the tablets disclosed in tables 1-1 and 1-2 above. Examples are Opadry® film coatings such as Opadry® 02A275000 light gray, Opadry® 02A240005 light pink or Opadry® 02A220009 light yellow.

B—Assessment of Physiological Effectiveness

B-1 In Vivo Assay for Detecting Natriuretic Activity in Conscious Rats with Activated RAAS

[0531] Wistar rats (ca. 250-500 g body weight) were kept with free access to feed (Altromin) and drinking water. From approx. 72 hours before the start of the test, the animals received, instead of the normal feed, exclusively reduced-salt feed with a sodium chloride content of 0.02% Sodium Chloride (ssniff R/M-H, 10 mm with 0.02% Na, S0602-E081, ssniff Spezialdiaten GmbH, D-59494 Soest). This sodium-reduced feed causes an activation of the RAAS in the animals during the 3 days run-in phase and therefore mimics a neuroendocrine activation which is characteristic for cardiorenal diseases. During the test, the animals were housed singly in metabolic cages suitable for rats of this weight class (Tecniplast Deutschland GmbH, D-82383 Hohenpeissenberg) with free access to reduced-salt feed and drinking water for up to 24 hours. At the start of the test, the substance to be tested was administered by means of gavage in a volume of 2-3 ml/kg of body weight of a suitable solvent PEG400). Control animals received only solvent (‘S’ or solvent in table 2 below). Controls and substance tests were carried out in parallel on the same day. Control groups and substance-dose groups each consisted of 6 to 10 animals. During the test, the urine excreted by the animals was continuously collected in a receiver on the base of the cage. The urine volume per collection time was determined separately for each animal, and the concentration of glucose, sodium and potassium excreted in the urine was measured by standard methods using a clinical-chemical analyzer system (ADVIA 2400, Siemens). The urine was typically collected for 24 hours in the metabolic cages.

B-2 In Vivo Assay for Detecting Natriuretic Activity in Chronically Treated Zucker Diabetic Fatty Rats

[0532] The Zucker diabetic fatty (ZDF) rat has a missense mutation in the gene coding the leptin receptor (fa/fa) and spontaneously develops insulin resistance, type 2 diabetes mellitus (T2DM), hyperlipidemia, moderate hypertension, and obesity, as well as progressive renal injury. Male homozygous animals develop diabetes mellitus from week 7 to 19 which is reflected in marked hyperglycemia. In addition to diabetic cardiac lesions (e.g. hypertrophy), renal pathology develops with proteinuria, mesangial expansion, macrophage infiltration, and interstitial fibrosis. Heterozygous animals are useful non-diabetic control animals since they develop neither obesity nor insulin resistance.

[0533] Male 6-7 weeks old obese (fa/fa) Zucker rats (Charles River) were placed on a high energy diet (Purina Rodent LabDiet 5008, PMI Nutrition. Richmond. Ind.) and were randomized to treatment groups or solvent group when the animals were hyperglycemic. Rats (n=14-16/group) received either solvent [ethanol/Solutol/H.sub.2O (10/40/50)] or test compounds in solvent once daily applied to (fa/fa) animals for 4 to 12 weeks.

[0534] During the experiment, the systolic blood pressure (determined by tail cuff), urine parameters (e.g. protein, glucose, electrolytes, creatinine, urea and uric acid) and blood plasma parameters (e.g. electrolytes, glucose, creatinine, urea and uric acid) were determined at regular intervals.

[0535] For the determination of urinary parameter the animals were housed singly in metabolic cages suitable for rats of this weight class (Tecniplast Deutschland GmbH, D-82383 Hohenpeissenberg) with free access to drinking water for up to 24 hours. The urine volume per collection time was determined separately for each animal, and the concentration of urinary glucose and electrolyte ions excreted in the urine was measured by standard methods by a clinical-chemical analyzer system (ADVIA 2400, Siemens). The urine was typically collected for 24 hours in metabolic cages. At the end of the chronic experiment, hemodynamic parameter (e.g. blood pressure, heart rate, maximum and minimum inotropy [dp/dt], relaxation time [tau], left ventricular pressure, left ventricular end diastolic pressure [LVEDP]) are measured, and the weights of heart, kidney and lung are determined, plasma and urine biomarkers (e.g. NT-proBNP) and gene expression of biomarkers by RT/TaqMan PCR following RNA isolation from cardiac and renal tissue are determined. Histopathology is performed with cardiac and renal tissue from animals of treatment groups and placebo groups.

B-3 Comparison of Monotherapy (Finerenone or Empagliflozin (SGLT2 Inhibitor)) with Combination Therapy (Combined Use of Finerenone and Empagliflozin (SGLT2 Inhibitor)) in Conscious Rats with Activated RAAS

[0536] In this comparison, eight different administrations were performed (cf. groups A to H):

[0537] Group A received the solvent (PEG400) only. This group serves as control group.

[0538] Groups B, C and D received three increasing dosages of empagliflozin (SGLT2 inhibitor) only. It serves to detect the effects of the monotherapy with SGLT2 inhibitor.

[0539] Group E received a finerenone only. It serves to detect the effect of the monotherapy with finerenone.

[0540] Groups F, G and H received finerenone and the three doses of SGLT2 inhibitor in combination, respectively. It serves to detect the effect of the combined therapy with finerenone and empagliflozin (SGLT2 inhibitor) (combination according to the invention).

[0541] After the treatment, the urinary volume, urinary glucose, urinary sodium and potassium concentrations were measured. Table 2 summarizes the results.

TABLE-US-00003 TABLE 2 Measured data (mean values ± standard error [SE]) of urinary volume, urinary glucose, urinary potassium concentration (K+), and urinary sodium concentration (Na+), from awake Wistar rats with activated renin-angiotensin-aldosterone system (n = 6-8 animals per group), which were examined according to the ‘assessment of the physiological efficacy’ for 24 hours after oral administration of the substances in metabolic cages. ‘b.d.l.’ means below detection limit of glucose in urine. Urinary Volume/ Urinary Glucose Urinary K+ Urinary Na+ body weight concentration concentration concentration Group [ml/kg] [mmol] [mmol] [mmol] A: Solvent 32.25 ± 7.44 b.d.l. 2.21 ± 0.32 0.19 ± 0.03 Mean value ± SEM B: 1 mg/kg empagliflozin 27.80 ± 3.58 0.34 ± 0.10 1.66 ± 0.11 0.15 ± 0.05 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM C: 3 mg/kg empagliflozin 22.96 ± 2.75 1.21 ± 0.21 1.74 ± 0.15 0.13 ± 0.02 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM D: 10 mg/kg empagliflozin 28.45 ± 1.91 4.26 ± 0.59 1.85 ± 0.11 0.17 ± 0.03 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM E: 1 mg/kg Finerenone 21.90 ± 1.86 b.d.l. 1.46 ± 0.12 0.43 ± 0.03 (Monotherapy) Mean value ± SEM F: Combination group 23.47 ± 3.47 1.11 ± 0.46 1.62 ± 0.27 0.71 ± 0.07 1 mg/kg empagliflozin p < 0.05 vs. E  p < 0.005 vs. B (SGLT2 inhibitor) + p < 0.01 vs. E  1 mg/kg Finerenone Mean value ± SEM G: Combination group 33.96 ± 2.79 1.54 ± 0.30 1.58 ± 0.14 0.96 ± 0.09 3 mg/kg empagliflozin p < 0.05 vs. C p < 0.005 vs. E p < 0.005 vs. C (SGLT2 inhibitor) + p < 0.01 vs. E p < 0.005 vs. E 1 mg/kg Finerenone Mean value ± SEM H: Combination group 36.76 ± 2.19 4.79 ± 0.50 1.75 ± 0.16 0.89 ± 0.09 10 mg/kg empagliflozin p < 0.05 vs. D p < 0.005 vs. E p < 0.005 vs. D (SGLT2 inhibitor) + 1 mg/kg  p < 0.005 vs. E p < 0.005 vs. E Finerenone Mean value ± SEM

[0542] The results are also depicted in FIG. 1.

[0543] FIG. 1: Influence of the SGLT2 inhibitor empagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on [0544] (a) urinary volume (FIG. 1a), [0545] (b) the urinary glucose concentration (FIG. 1b), [0546] (c) the urinary potassium concentration (FIG. 1c), [0547] (d) the urinary sodium concentration (FIG. 1d), and
of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B above, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=6-8 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg empagliflozin (group B), 3 mg/kg empagliflozin (group C), 10 mg/kg empagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg empagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg empagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg empagliflozin+1 mg/kg finerenone combination (group H).

[0548] From table 2 and FIG. 1 a to d the following can be concluded:

[0549] Group A (solvent only), in which the solvent (PEG400) was administered, shows the physiological excretion of volume, potassium and sodium of conscious rats over 24 hours under RAAS activation.

[0550] Groups B, C and D (monotherapy empagliflozin (SGLT2 inhibitor)) show that administration of empagliflozin has no influence on urinary volume, urinary potassium and urinary sodium at the indicated doses but leads to a dose-dependent and strong increase in urinary glucose.

[0551] Group E (monotherapy finerenone) shows that administration of 1 mg/kg of finerenone has no influence on urinary volume, urinary glucose and urinary potassium, but causes an increase in urinary sodium.

[0552] Groups F, G and H (combination of finerenone and empagliflozin (SGLT2 inhibitor)) show that administration of a combination of 1 mg/kg finerenone and 1 to 10 mg/kg empagliflozin (SGLT2 inhibitor) does not increase urinary glucose and urinary potassium in comparison to the respective individual finerenone and empagliflozin (SGLT2 inhibitor) dosage, but increases urinary volume at the two higher combination dosages and dose-dependently and strongly induces sodium excretion in all combination groups in comparison to the respective individual finerenone and empagliflozin (SGLT2 inhibitor).

[0553] A comparison of group A (solvent) with groups F, G and H (combination finerenone and empagliflozin (SGLT2 inhibitor)) shows that administration of a combination of finerenone and empagliflozin (SGLT2 inhibitor) that chronic administration of a combination of finerenone and the SGLT2 inhibitor increases the urinary sodium excretion from 1.16±0.06 mmol (group A) to 0.71±0.07 mmol (group F, combination), 0.96±0.09 mmol (group G, combination), and 0.89±0.09 mmol (group H, combination),

[0554] A comparison of groups B, C, D and E (monotherapy with empagliflozin or finerenone) with groups F, G and H (combination finerenone and empagliflozin (SGLT2 inhibitor)) shows that administration of a combination of finerenone and empagliflozin (SGLT2 inhibitor) that chronic administration of a combination of finerenone and the SGLT2 inhibitor increases the urinary sodium excretion from 0.15±0.05 mmol (group B, monotherapy empagliflozin), 0.13±0.02 mmol (group C, monotherapy empagliflozin), 0.17±0.03 mmol (group D, monotherapy empagliflozin), 0.43±0.03 mmol (group E, monotherapy empagliflozin), to 0.71±0.07 mmol (group F, combination), 0.96±0.09 mmol (group G, combination), and 0.89±0.09 mmol (group H, combination). This is surprising as the combination of finerenone and empagliflozin (SGLT2 inhibitor) shows an over-additive effect.

[0555] Note that the urinary sodium concentration is statistically significant higher. The urinary sodium excretion of the combination therapy is more than the pure sum of the respective monotherapies. Thereby showing an over-additive effect in comparison to the respective monotherapy. Therefore, the combination of finerenone and empagliflozin (SGLT2 inhibitor) under typical conditions of activated RAAS leads to a significant natriuretic efficacy improvement over the sum of the monotherapies. This natriuretic efficacy improvement is a major clinical goal in the treatment of cardiovascular and/or cardiorenal diseases such as heart failure and CKD.

B-4 Comparison of Monotherapy (Finerenone or a SGLT2 Inhibitor) with Combination Therapy (Combined Use of Finerenone and a SGLT2 Inhibitor) in Chronically Treated Zucker Diabetic Fatty Rats

[0556] In this comparison, six different administrations were performed:

[0557] Group A received the solvent [ethanol/Solutol/H.sub.2O (10/40/50)] only. This group serves as control group.

[0558] Groups B and C received two increasing dosages of empagliflozin (SGLT2 inhibitor) only. It serves to detect the effects of the monotherapy with empagliflozin (SGLT2 inhibitor).

[0559] Groups D and E received increasing dosages of finerenone only. It serves to detect the effect of the monotherapy with finerenone.

[0560] Group F received a combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone, respectively. It serves to detect the effect of the combined therapy with finerenone and empagliflozin (SGLT2 inhibitor) (combination according to the invention).

[0561] After the treatment, the urinary volume, urinary glucose, urinary sodium and potassium concentrations were measured. Table 3 summarizes the results.

TABLE-US-00004 TABLE 3 Measured data (mean values ± standard error [SE]) of urinary volume, urinary glucose, urinary potassium concentration (K+), and urinary sodium concentration (Na+), from awake diabetic ZDF rats chronically treated for 9 weeks with either solvent, two dosages of SGLT2 inhibitor, two dosages of finerenone, or a combination of the low dosages of SGLT2 inhibitor and finerenone (n = 14-16 animals per group), which were examined according to the ‘assessment of the physiological efficacy’ for 24 hours in metabolic cages. Urinary Volume/ Urinary Glucose Urinary K+ Urinary Na+ body weight concentration concentration concentration Group [ml/kg] [mmol] [mmol] [mmol] A: Solvent 63.77 ± 2.82 249.65 ± 20.96 1.95 ± 0.08 1.16 ± 0.06 Mean value ± SEM B: 3 mg/kg 99.98 ± 7.12 321.55 ± 22.78 2.22 ± 0.13 1.47 ± 0.10 empagliflozin (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM C: 10 mg/kg 110.38 ± 4.55  317.16 ± 25.10 2.64 ± 0.20 2.05 ± 0.27 empagliflozin (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM D: 3 mg/kg Finerenone  81.84 ± 11.99 291.98 ± 19.11 1.94 ± 0.14 1.39 ± 0.12 (Monotherapy) Mean value ± SEM E: 10 mg/kg 56.82 ± 2.59 272.62 ± 22.51 1.75 ± 0.06 1.30 ± 0.08 Finerenone (Monotherapy) Mean value ± SEM F: Combination group 109.12 ± 3.30  338.87 ± 10.86 2.13 ± 0.10 2.07 ± 0.15 3 mg/kg empagliflozin p < 0.05 vs. D p < 0.05 vs. D p < 0.01 vs. B (SGLT2 inhibitor) + 3 p < 0.01 vs. D mg/kg Finerenone Mean value ± SEM

[0562] The results are also depicted in FIG. 2.

[0563] FIG. 2: Influence of two dosages of the SGLT2 inhibitor empagliflozin (groups B and C), two dosages of the MR antagonist finerenone (groups D and E), and the combination of the low dosages of empagliflozin (SGLT2 inhibitor) and finerenone (group F), respectively, on

[0564] (a) urinary volume (FIG. 2a),

[0565] (b) the urinary glucose concentration (FIG. 2b),

[0566] (c) the urinary potassium concentration (FIG. 2c),

[0567] (d) the urinary sodium concentration (FIG. 2d), and

of awake ZDF rats chronically treated with groups A to F, which were examined according to section B above, ‘assessment of the physiological effectiveness’ for 24 hours in metabolic cages. n=14-16 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 3 mg/kg empagliflozin (group B), 10 mg/kg empagliflozin (group C), 3 mg/kg finerenone (group D), 10 mg/kg finerenone (group E), 3 mg/kg empagliflozin+3 mg/kg finerenone combination (group F).

[0568] From table 3 and FIG. 2 (a) to (d) the following can be concluded:

[0569] Group A (solvent), in which the solvent ([ethanol/Solutol/H.sub.2O (10/40/50)]) was administered, shows the excretion of volume, glucose, potassium and sodium of conscious Zucker diabetic fatty rats over 24 hours after a treatment period of 9 weeks.

[0570] A comparison of group A (solvent) with groups B and C (monotherapy empagliflozin (SGLT2 inhibitor)) show that chronic administration of a SGLT2 inhibitor increases urinary volume, urinary glucose, urinary potassium and urinary sodium. When comparing the solvent group A with the empagliflozin (SGLT2 inhibitor) monotherapy it can be seen that the urinary sodium excretion is 27.2% higher in comparison to solvent control group A.

[0571] A comparison of group A (solvent) with groups D and E (monotherapy finerenone) shows that chronic administration of finerenone has no influence on urinary volume, urinary glucose, urinary potassium and urinary sodium at the indicated dosages of 3 and 10 mg/kg/day. When comparing the solvent group A with the finerenone monotherapy it can be seen that the urinary sodium excretion is 20.1% higher in comparison to solvent control group A.

[0572] A comparison of the low dosage groups B (3 mg/kg empagliflozin (SGLT2 inhibitor), monotherapy) and D (3 mg/kg finerenone, monotherapy) with group F (combination finerenone and empagliflozin (SGLT2 inhibitor)) shows that administration of a combination of finerenone and empagliflozin (SGLT2 inhibitor) does not increase urinary volume, glucose and urinary potassium in comparison to the respective individual finerenone and SGLT2 inhibitor dosages, but leads to a statistically significant increase in urinary sodium excretion that is approx. 41 to approx. 58% higher in comparison to the respective monotherapies. This is surprising as the combination of finerenone and empagliflozin (SGLT2 inhibitor) shows an over-additive effect.

[0573] In summary, the urinary sodium excretion is 27.2% and 20.1% higher for the 3 mg/kg empagliflozin (SGLT2 inhibitor) and 3 mg/kg finerenone dosages, respectively, in comparison to the solvent control (group A), while the combined urinary sodium excretion of the combination of finerenone and empagliflozin is 78.25% higher in comparison to solvent control group A and, thus, more than the sum of the respective monotherapies. Thus, in comparison to the respective monotherapies, the sodium excretion of the combination is approx. 41 to approx. 58% higher.

[0574] Therefore, the combination of finerenone and empagliflozin (SGLT2 inhibitor) under typical chronic conditions including insulin resistance, type 2 diabetes mellitus, hyperlipidemia, hypertension, and obesity, as well as progressive renal injury leads to a significant natriuretic efficacy improvement over the sum of the monotherapies. This natriuretic efficacy improvement is a major clinical goal in the treatment of cardiovascular and/or cardiorenal diseases such as heart failure and CKD.

B-5 Combined Efficacy of Nonsteroidal MR Antagonist Finerenone and SGLT2 Inhibitor Empagliflozin in a Non-Diabetic Cardiorenal Rat Model

[0575] Method:

[0576] Cardiorenal morbidity and mortality was studied in hypertensive and proteinuric L-NAME (20 mg/L) treated renin-transgenic (mRen2)27 rats. Rats (10-11 weeks old female, n=13-17/group) were treated once daily orally for up to 7 weeks with placebo, finerenone (1 and 3 mg/kg), empagliflozin (3 and 10 mg/kg), or a combination of the respective low doses. Key outcome parameters included mortality, blood pressure, proteinuria, kidney histology and gene expression.

[0577] L-NAME-Treated Transgenic Renin Rat (TGR(mRen2)27):

[0578] The transgenic renin rat ‘TGR(mRen2)27’ is a hypertensive rat line developed by Mullins and Ganten which overexpresses the Ren-2 gene of the mouse. Additional administration of the nitrogen monoxide synthase inhibitor L-NAME induces endothelial dysfunction which increases morbidity and mortality in this model. Unless subjected to life-long antihypertensive therapy, homozygous animals die of secondary complications such as heart and kidney failure or stroke.

[0579] Female TGR(mRen2)27 renin rats aged 10 to 20 weeks are randomized to different pharmacological treatment groups and a placebo group. In addition, the nitrogen monoxide synthase inhibitor L-NAME is administered via the drinking water in a concentration of 20 to 100 mg/l. During the entire experiment, drinking water and feed are available ad libitum to the animals. The substances are administered via the feed or daily by gavage for 4-10 weeks. Animals treated in the same way but receiving either only the solvent or the feed without test substance serve as placebo group. During the experiment, the systolic blood pressure is determined at regular intervals using a tail cuff, and proteinuria (expressed as ratio of urinary protein concentration per urinary creatinine concentration) and urine electrolyte composition are determined by collecting the urine in metabolic cages, and mortality is registered on a daily base. At the end of the experiment, haemodynamic parameters (blood pressure, heart rate, inotropism [dp/dt], relaxation time [tau], maximum left ventricular pressure, left ventricular end-diastolic pressure [LVEDP]) are measured, and the weights of heart, kidney and lung are determined, protein elimination and biomarkers (e.g. ANP, RIA Kit RK 005-24, Phoenix Pharmaceuticals, Inc., USA, cGMP, RIA Kit RE29075, IBL International GmbH, Hamburg, Germany, renin, angiotensin I, RIA Kit CA-1533, DiaSorin S.p.A., Italy, and aldosterone, P2714, DiaSorin S.p.A., Italy), renal and cardiac histopathology and gene expression of biomarkers by RT/TaqMan PCR following RNA isolation from cardiac and renal tissue are determined.

[0580] For the determination of urinary parameter the animals were housed singly in metabolic cages suitable for rats of this weight class (Tecniplast Deutschland GmbH, D-82383 Hohenpeissenberg) with free access to drinking water for up to 24 hours. The urine volume per collection time was determined separately for each animal, and the concentration of urinary glucose and electrolyte ions excreted in the urine was measured by standard methods by a clinical-chemical analyzer system (ADVIA 2400, Siemens). The urine was typically collected for 24 hours in metabolic cages.

[0581] Results:

[0582] Placebo-treated rats demonstrated a 50% mortality rate over the course of 7 weeks (FIG. 3a). Drug treatment resulted in variable degrees of survival benefit, most prominent and statistically significant in the low dose combination group (FIG. 3a). Low dose combination revealed an early, sustained and efficacious proteinuria reduction (−86%, p<0.05; FIG. 3b) and was highly efficient on renal histology parameters. Monotherapies of finerenone (−27% at 1 mg/kg, p=n.s.; −87% at 3 mg/kg, p<0.05; FIG. 3b) and empagliflozin (−38% at 3 mg/kg, p=n.s.; −64% at 10 mg/kg, p=n.s.; FIG. 3b) dose-dependently reduced proteinuria with a comparable protection from renal lesions at higher dosages. Treatment with finerenone and the combination significantly decreased systolic blood pressure while empagliflozin alone and in combination acted strongly glucosoric.

[0583] Conclusion:

[0584] Both, MRA by finerenone and SGLT2 inhibitor by empagliflozin confer renal protection in preclinical non-diabetic, hypertensive kidney disease. Combination of these two modes of action at low dosages revealed efficacious reduction in proteinuria (see FIG. 3b) and mortality indicating a strong potential for combined clinical use in respective cardiorenal patient populations.

B-6 Comparison of Monotherapy (Finerenone or Canagliflozin (SGLT2 Inhibitor)) with Combination Therapy (Combined Use of Finerenone and Canagliflozin (SGLT2 Inhibitor)) in Conscious Rats with Activated RAAS

[0585] In this comparison, eight different administrations were performed (cf. groups A to H):

[0586] Group A received the solvent (PEG400) only. This group serves as control group.

[0587] Groups B, C and D received three increasing dosages of canagliflozin (SGLT2 inhibitor) only. It serves to detect the effects of the monotherapy with SGLT2 inhibitor.

[0588] Group E received a finerenone only. It serves to detect the effect of the monotherapy with finerenone.

[0589] Groups F, G and H received finerenone and the three doses of SGLT2 inhibitor in combination, respectively. It serves to detect the effect of the combined therapy with finerenone and canagliflozin (SGLT2 inhibitor) (combination according to the invention).

[0590] The method as described in sections B1 was used.

TABLE-US-00005 TABLE 4 Urinary Volume/ Urinary Glucose Urinary K+ Urinary Na+ body weight concentration concentration concentration Group [ml/kg] [mmol] [mmol] [mmol] A: Solvent 38.98 ± 4.23 b.d.l. 1.91 ± 0.13 0.10 ± 0.03 Mean value ± SEM B: 1 mg/kg canagliflozin 31.08 ± 3.17 2.76 ± 0.36 1.86 ± 0.11 0.15 ± 0.03 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM C: 3 mg/kg canagliflozin 40.49 ± 2.43 6.94 ± 0.44 2.40 ± 0.17 0.21 ± 0.05 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM D: 10 mg/kg canagliflozin 55.83 ± 3.52 9.99 ± 0.46 2.36 ± 0.15 0.41 ± 0.08 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM E: 1 mg/kg finerenone 29.32 ± 2.94 b.d.l. 1.76 ± 0.11 0.27 ± 0.06 (Monotherapy) Mean value ± SEM F: Combination group 34.17 ± 3.98 2.97 ± 0.28 1.71 ± 0.08 0.33 ± 0.04 1 mg/kg canagliflozin p < 0.005 vs. E p < 0.01 vs. B  (SGLT2 inhibitor) + 1 mg/kg finerenone Mean value ± SEM G: Combination group 48.40 ± 4.44 6.13 ± 0.61 1.83 ± 0.19 0.67 ± 0.06 3 mg/kg canagliflozin p < 0.01 vs. E  p < 0.005 vs. E p < 0.05 vs. C p < 0.005 vs. C (SGLT2 inhibitor) + p < 0.005 vs. E 1 mg/kg finerenone Mean value ± SEM H: Combination group 56.54 ± 4.09 9.30 ± 0.71 1.97 ± 0.14 0.96 ± 0.06 10 mg/kg canagliflozin p < 0.005 vs. E p < 0.005 vs. E p < 0.005 vs. D (SGLT2 inhibitor) + p < 0.005 vs. E 1 mg/kg finerenone Mean value ± SEM

[0591] The results are also depicted in FIG. 4.

[0592] FIG. 4: Influence of the SGLT2 inhibitor canagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on

[0593] (a) urinary volume (FIG. 4a),

[0594] (b) the urinary glucose concentration (FIG. 4b),

[0595] (c) the urinary potassium concentration (FIG. 4c), and

[0596] (d) the urinary sodium concentration (FIG. 4d),

of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B above, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=9-10 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 1 mg/kg canagliflozin (group B), 3 mg/kg canagliflozin (group C), 10 mg/kg canagliflozin (group D), 1 mg/kg finerenone (group E), 1 mg/kg canagliflozin+1 mg/kg finerenone combination (group F), 3 mg/kg canagliflozin+1 mg/kg finerenone combination (group G), 10 mg/kg canagliflozin+1 mg/kg finerenone combination (group H).

[0597] From table 4 and FIG. 4 a to d the following can be concluded:

[0598] Group A (solvent only), in which the solvent (PEG400) was administered, shows the physiological excretion of volume, potassium and sodium of conscious rats over 24 hours under RAAS activation.

[0599] Groups B, C and D (monotherapy canagliflozin (SGLT2 inhibitor)) show that administration of canagliflozin has no influence on urinary volume, urinary potassium and urinary sodium at the doses of 1 and 3 mg/kg while a dose of 10 mg/kg induces an increase in urinary volume and urinary sodium. All doses of canagliflozin induce a strong increase in urinary glucose.

[0600] Group E (monotherapy finerenone) shows that administration of 1 mg/kg of finerenone has no influence on urinary volume, urinary glucose and urinary potassium, but causes a weak increase in urinary sodium.

[0601] Groups F, G and H (combination of finerenone and canagliflozin (SGLT2 inhibitor)) show that administration of a combination of 1 mg/kg finerenone and 1 to 10 mg/kg canagliflozin does not increase urinary glucose in comparison to the respective individual canagliflozin dosages (finerenone alone has no effect on urinary glucose), and does not increase urinary volume in comparison to the respective individual canagliflozin dosages but strongly induces sodium excretion in the two higher combination groups (1 mg/kg finerenone and 3 mg/kg canagliflozin; 1 mg/kg finerenone and 10 mg/kg canagliflozin) in comparison to the respective individual finerenone and canagliflozin (SGLT2 inhibitor) dosage groups.

[0602] Note that the urinary sodium concentration is statistically significant higher in the combination groups of 3 and 10 mg/kg canagliflozin with 1 mg/kg finerenone, respectively. The urinary sodium excretion of the combination therapy is more than the pure sum of the respective monotherapies. Thereby showing an over-additive effect in comparison to the respective monotherapy. Therefore, the combination of finerenone and canagliflozin (SGLT2 inhibitor) under typical conditions of activated RAAS leads to a significant natriuretic efficacy improvement over the sum of the monotherapies. This natriuretic efficacy improvement is a major clinical goal in the treatment of cardiovascular and/or cardiorenal diseases such as heart failure and CKD.

B-7 Comparison of Monotherapy (Finerenone or Dapagliflozin (SGLT2 Inhibitor)) with Combination Therapy (Combined Use of Finerenone and Dapagliflozin (SGLT2 Inhibitor)) in Conscious Rats with Activated RAAS

[0603] In this comparison, eight different administrations were performed (cf. groups A to H): Group A received the solvent (PEG400) only. This group serves as control group. Groups B, C and D received three increasing dosages of dapagliflozin (SGLT2 inhibitor) only. It serves to detect the effects of the monotherapy with SGLT2 inhibitor. Group E received a finerenone only. It serves to detect the effect of the monotherapy with finerenone. Groups F, G and H received finerenone and the three doses of SGLT2 inhibitor in combination, respectively. It serves to detect the effect of the combined therapy with finerenone and dapagliflozin (SGLT2 inhibitor) (combination according to the invention). The following methods as described in sections B1 (with 10 animals per group) were used.

TABLE-US-00006 TABLE 5 Urinary Volume/ Urinary Glucose Urinary K+ Urinary Na+ body weight concentration concentration concentration Group [ml/kg] [mmol] [mmol] [mmol] A: Solvent 26.45 ± 2.14 b.d.l. 1.91 ± 0.09 0.08 ± 0.02 Mean value ± SEM B: 0.03 mg/kg dapagliflozin 39.17 ± 4.08 0.72 ± 0.18 2.21 ± 0.16 0.19 ± 0.05 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM C: 0.3 mg/kg dapagliflozin 38.84 ± 3.94 5.26 ± 0.29 2.43 ± 0.07 0.19 ± 0.04 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM D: 3 mg/kg dapagliflozin 48.72 ± 1.53 9.71 ± 0.36 2.34 ± 0.10 0.29 ± 0.05 (SGLT2 inhibitor) (Monotherapy) Mean value ± SEM E: 1 mg/kg finerenone 23.44 ± 1.62 b.d.l. 1.84 ± 0.10 0.33 ± 0.43 (Monotherapy) Mean value ± SEM F: Combination group 36.05 ± 5.04 0.74 ± 0.16 1.95 ± 0.15 0.56 ± 0.07 0.03 mg/kg dapagliflozin p < 0.05 vs. E p < 0.005 vs. E p < 0.005 vs. B (SGLT2 inhibitor) + p < 0.05 vs. E  1 mg/kg finerenone Mean value ± SEM G: Combination group 33.18 ± 1.95 4.42 ± 0.36 1.74 ± 0.08 0.51 ± 0.04 0.3 mg/kg dapagliflozin p < 0.01 vs. E p < 0.005 vs. E p < 0.005 vs. C p < 0.005 vs. C (SGLT2 inhibitor) + p < 0.01 vs. E  1 mg/kg finerenone Mean value ± SEM H: Combination group 50.89 ± 2.00 9.84 ± 0.49 2.22 ± 0.13 0.83 ± 0.12 3 mg/kg dapagliflozin  p < 0.005 vs. E p < 0.005 vs. E p < 0.05 vs. E  p < 0.005 vs. D (SGLT2 inhibitor) + p < 0.005 vs. E 1 mg/kg finerenone Mean value ± SEM

[0604] The results are also depicted in FIG. 5.

[0605] FIG. 5: Influence of the SGLT2 inhibitor dapagliflozin (groups B-D), of the MR antagonist finerenone (E), and their combination (groups F-H) on

[0606] (a) urinary volume (FIG. 5a),

[0607] (b) the urinary glucose concentration (FIG. 5b),

[0608] (c) the urinary potassium concentration (FIG. 5c), and

[0609] (d) the urinary sodium concentration (FIG. 5d),

of awake Wistar rats with activated renin-angiotensin-aldosterone system, which were examined according to section B above, ‘assessment of the physiological effectiveness’ for 24 hours after oral administration of the substances in metabolic cages. n=10 animals/per group. +: p<0.05 vs. combination group, ++: p<0.01 vs. combination group, +++: p<0.005 vs. combination group, ‘ns’ means not significant vs. combination group. S means solvent (group A). 0.03 mg/kg dapagliflozin (group B), 0.3 mg/kg dapagliflozin (group C), 3 mg/kg dapagliflozin (group D), 1 mg/kg finerenone (group E), 0.03 mg/kg dapagliflozin+1 mg/kg finerenone combination (group F), 0.3 mg/kg dapagliflozin+1 mg/kg finerenone combination (group G), 3 mg/kg dapagliflozin+1 mg/kg finerenone combination (group H).

[0610] From table 5 and FIG. 5 a to d, the following can be concluded:

[0611] Group A (solvent only), in which the solvent (PEG400) was administered, shows the physiological excretion of volume, potassium and sodium of conscious rats over 24 hours under RAAS activation.

[0612] Groups B, C and D (monotherapy dapagliflozin (SGLT2 inhibitor)) show that administration of dapagliflozin has no influence on urinary volume, urinary potassium and urinary sodium at the doses of 0.03 and 0.3 mg/kg while a dose of 3 mg/kg induces an increase in urinary volume and urinary sodium. All doses of dapagliflozin induce a strong increase in urinary glucose.

[0613] Group E (monotherapy finerenone) shows that administration of 1 mg/kg of finerenone has no influence on urinary volume, urinary glucose and urinary potassium, but causes an increase in urinary sodium.

[0614] Groups F, G and H (combination of finerenone and dapagliflozin (SGLT2 inhibitor)) show that administration of a combination of 1 mg/kg finerenone and 0.03 to 3 mg/kg dapagliflozin does not increase urinary glucose in comparison to the respective individual dapagliflozin dosages (finerenone alone has no effect on urinary glucose), and does not increase urinary volume in comparison to the respective individual dapagliflozin dosages but strongly induces sodium excretion in all combination groups (1 mg/kg finerenone and 0.03 mg/kg dapagliflozin; 1 mg/kg finerenone and 0.3 mg/kg dapagliflozin; 1 mg/kg finerenone and 3 mg/kg dapagliflozin) in comparison to the respective individual finerenone and dapagliflozin (SGLT2 inhibitor) dosage groups.

[0615] Note that the urinary sodium concentration is statistically significant higher in all combination groups of 0.03 to 3 mg/kg dapagliflozin with 1 mg/kg finerenone, respectively. The urinary sodium excretion of the combination therapy with 0.03 mg/kg dapagliflozin and 1 mg/kg finerenone and the combination therapy of 3 mg/kg dapagliflozin and 1 mg/kg finerenone is more than the pure sum of the respective monotherapies. Thereby showing an over-additive effect in comparison to the respective monotherapy. Therefore, the combination of finerenone and canagliflozin (SGLT2 inhibitor) under typical conditions of activated RAAS leads to a significant natriuretic efficacy improvement over the sum of the monotherapies. This natriuretic efficacy improvement is a major clinical goal in the treatment of cardiovascular and/or cardiorenal diseases such as heart failure and CKD.