Baxdrostat a Selective Aldosterone Synthase Inhibitor in Resistant Hypertension: A Narrative Review of Mechanism Efficacy and Safety

Baxdrostat is an orally administered, selective aldosterone synthase inhibitor developed as a novel pharmacological approach for hypertension that remains inadequately controlled despite antihypertensive therapy. Unlike mineralocorticoid receptor antagonists, baxdrostat acts upstream by inhibiting CYP11B2, the enzyme responsible for the final steps of aldosterone biosynthesis, while retaining high selectivity over CYP11B1, the enzyme required for cortisol synthesis. In the phase 2 BrigHTN trial, baxdrostat produced dose-related reductions in systolic blood pressure in treatment-resistant hypertension. In the phase 3 BaxHTN trial (n = 796), placebo-adjusted reductions in seated systolic blood pressure at 12 weeks were 8.7 mmHg with 1 mg and 9.8 mmHg with 2 mg once daily, and in the phase 3 Bax24 trial the placebo-corrected reduction in 24-hour ambulatory systolic blood pressure was 14.0 mmHg. In May 2026 the U.S. FDA approved baxdrostat (Baxfendy) as an add-on treatment for adults whose hypertension is not adequately controlled with other antihypertensive medicines. The principal safety concerns are hyperkalemia and hyponatremia, which require baseline and periodic laboratory monitoring and dose individualization. This review summarizes the pathophysiological rationale, pharmacology, pharmacokinetics and pharmacodynamics, clinical evidence, safety, dosing and monitoring, comparison with existing therapies, regulatory status and future therapeutic role of baxdrostat.