Johnson & Johnson has secured FDA approval for Akeega, a combination tablet for first-line treatment of adults with BRCA-positive metastatic castration-resistant prostate cancer (mCRPC). The decision follows earlier regulatory approvals in the European Union and Canada, establishing Akeega as the first dual-action tablet combining J&J's PARP inhibitor niraparib with abiraterone acetate, the active ingredient in blockbuster androgen inhibitor Zytiga.
Targeted Patient Population
The FDA approval restricts Akeega's use to patients with BRCA1 or BRCA2 mutations, representing approximately 10% to 15% of mCRPC patients. This patient subset typically experiences poorer outcomes and shorter survival times compared to those without these genetic alterations. Patient organization ZERO Prostate Cancer characterized Akeega as an "important option" for patients with this form of cancer while highlighting "the need for the importance of genetic testing and precision medicine for this disease."
Clinical Trial Results
The FDA approval draws on the MAGNITUDE phase 3 trial, which demonstrated that adding niraparib to Zytiga plus prednisone or prednisolone significantly improved radiographic progression-free survival (rPFS) by 47% compared to standard of care in untreated mCRPC patients with BRCA1/2 mutations. However, Akeega failed to improve rPFS compared to Zytiga alone in mCRPC patients without homologous recombination repair (HRR) mutations, of which BRCA accounts for around half of all cases.
For the overall patient group in the trial, the improvement in rPFS was 27%. After two years of follow-up, investigators reported a trend towards improved survival with Akeega in patients with BRCA mutations, but not in the larger HRR-positive group.
Competitive Landscape
In the US market, Akeega faces competition from AstraZeneca and MSD's rival PARP inhibitor Lynparza (olaparib), which is also restricted to BRCA-mutated patients when used in combination with Zytiga. This creates a level playing field between the two combinations in the American market, unlike in Europe where Lynparza can be used across all mCRPC patients without mutation testing requirements.
A third competitor, Pfizer's PARP inhibitor Talzenna (talazoparib), received approval for mCRPC patients with HRR mutations in June. The Talzenna combination showed a 37% reduction in rPFS in an all-comer population when combined with anti-androgen therapy Xtandi (enzalutamide) in the TALAPRO-2 study, and a 55% reduction for patients with HRR mutations.
Market Context
Prostate cancer represents the second-most commonly diagnosed cancer in men. Despite an increase in available treatments for men with mCRPC, five-year survival remains low at around 15%. The approval of Akeega adds another precision medicine option for the subset of patients with BRCA mutations, who face particularly challenging prognoses.
J&J holds rights to niraparib in prostate cancer under a 2016 licensing agreement with original developer Tesaro, signed before Tesaro's acquisition by GSK. GSK retains rights to niraparib for all other indications, including ovarian, fallopian tube, and peritoneal cancers.
