- 2 days ago
What if the next medical breakthrough isn’t a new drug but a new use for an old one? Can Malaysia position itself as a hub for drug repurposing in the region? On this episode of #ConsiderThis Melisa Idris speaks with Dr Sanjeev Krishna, Professor of Molecular Parasitology and Medicine at City St George's University of London, and Dr Yolanda Augustin, Clinical Oncologist at City St George’s University of London.
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00:00Music
00:10Hello and good evening, I'm Melissa Idris. Welcome to Consider This.
00:14This is the show where we want you to consider and then reconsider what you know of the news of
00:18the day.
00:19It's been almost a year since we last spoke to the International Affordable Diagnostics and Therapeutic Alliance
00:25or IAIDATA about its vision for a more affordable and accessible healthcare across the Global South.
00:33Today on the show, we're bringing back the good folks from IAIDATA to give us an update of the progress
00:39of the last year.
00:41I have with me Professor Emeritus Dr. Sanjeev Krishna, Professor of Molecular Parasitology and Medicine
00:48at City St. George's University of London and Dr. Yolanda Agustin,
00:52who is a clinical oncologist at City St. George's University of London as well.
00:57Welcome to the show. Welcome back, Professor Sanjeev. It's good to have you back, Yolanda, back on the show.
01:03So it's been almost a year since we, almost exactly a year since we last, you last introduced us to
01:09IAIDATA.
01:11And much of that conversation around the time talked a lot about the ambition and the vision of the Alliance,
01:17but we also focused a lot on the development of diagnostics.
01:21So I'm very curious to know what you've been up to in the past year and how you would assess
01:28the progress that's been made in the past year.
01:31Melissa, it's so wonderful to come back. I have to offer you small congratulations for getting IAIDATA right.
01:39It is such a mouthful.
01:41You know, that's great. And also, you know, for giving us this chance to share some of the excitement,
01:47because, you know, the therapeutic side of IAIDATA has really moved on.
01:54But I just wanted to start off, if you like, just by setting the scene a little bit, if I
02:00may.
02:00Sure.
02:00Because I think one of the most heartening things that I personally have found working with colleagues like Dr. Yolanda
02:10and the whole team
02:11is how permissive, how attractive Malaysia is for the ideas that we're going to discuss.
02:21And for me, this, you know, the scene was that I was at Clinical Research Malaysia at a conference which
02:29was organized
02:29by the great Dr. Akmal, who heads CRM, and it's such a great success story for Malaysia.
02:37And last week, you know, we had a Connect meeting.
02:40And Y.B. Dr. Datuk Shree Dhul, the minister, our minister of health, spoke.
02:54And he, in his words, reflected the whole Madani approach when he said,
03:02And science must act in the name of humanity.
03:10Science without humanity loses its purpose.
03:14I was so taken with those words because they reflect the whole Madani approach.
03:18You know, Madani wants to reach to people who are not accessed.
03:22And the pillars that you, you know, some of the pillars in Madani are very much therapeutics and diagnostics.
03:29So, the therapeutic side, which is what we're here to discuss today.
03:34If you look in the global progress sheet, if you're marking the scorecards,
03:40you know, the advances are phenomenal scientifically.
03:43You have new genetic treatment. You can cure genetic diseases.
03:47My old professor had this as a dream. It's now happening.
03:50You know, you can develop treatments for cancers, antibody treatments.
03:55But where are they?
03:57A treatment for cancer, which we'll hear more about, you know, maybe a quarter of a million dollars for a
04:03treatment course.
04:05Genetic diseases, oh, you have to go up a notch.
04:07You know, two million, one to two million.
04:09And you have a cure, but who can access that cure?
04:13So, access and affordability are our driving sort of ambitions.
04:17And we want to tie that very much to the highest quality science so that we are delivering progress.
04:25And within that, the areas we're focused on are the management of cancers.
04:30I actually am very happy to hear you talk about therapeutics because in our conversation last,
04:38you had mentioned almost in passing, you talked a little bit about how repurposing anti-malarial drugs for cancer care.
04:49And it stayed with me because I thought, what?
04:53I personally thought, oh my goodness, what a connection to be made.
04:59And now I understand that you've begun clinical trials on this.
05:04I mean, that's a huge leap of progress in the past year.
05:08Can you tell me more about it?
05:09Yeah, I know. Thank you so much.
05:10So, I think it's very exciting.
05:11So, we've been working actually at City St. George's now for more than 10 years on an anti-malarial drug
05:16called artesinate.
05:18So, it's actually very interesting because this drug comes from traditional Chinese medicine.
05:21It's a medicinal herb.
05:23And actually, one of the scientists, Chinese scientists that led on its discovery, Professor Tu Yu Yu,
05:28she won the Nobel Prize for Medicine back in 2015.
05:31So, again, I think it's quite exciting that a drug that basically has been discovered in the global south
05:36and actually has done so much to cure malaria in millions of patients can now be repurposed for cancer.
05:44And repurposing, I think, is a really exciting strategy for countries in the global south
05:50because it's taking drugs that are generic, that are usually off-patent and usually very affordable.
05:56So, for artesinate, for example, it's four ringgit per daily dose.
05:59And we also know its safety profile very well.
06:02So, we're taking this drug now to basically look at repurposing it for colorectal cancer
06:07and also for pre-cervical cancer.
06:10So, we have two phase two clinical trials that are running in Malaysia
06:13and we're doing that together with University Malaya and also Ministry of Health Hospitals.
06:17And then we also have colleagues in a Christian medical centre, VELOR, in India
06:21that are repurposing it for acute myeloid leukemia.
06:25So, all together, very exciting to see this work coming together.
06:28If I may get you to maybe rewind back a bit.
06:32So, for many viewers today, maybe they had the same reaction like me,
06:36going, how does a malaria drug end up being tested for cancer treatment?
06:43I mean, talk to me about that leap of scientific logic
06:47and how significant is that development scientifically?
06:51So, I think it's a very interesting process.
06:57So, I mean, we basically start with surveys, sort of general surveys
07:01to look at the mechanism of action.
07:03So, we look at lab-based studies.
07:05And with artesinate, there's more than 1,000 papers
07:07showing that it potentially has anti-cancer activity.
07:10And it appears to be targeting actually lots of different cancer pathways.
07:14So, I think that's actually a very novel and a very interesting property of the drug.
07:19And then from there, we now have artificial intelligence.
07:21We have bioinformatics that basically can be used to also screen for drugs
07:26as part of drug selection.
07:27So, that's what we're also doing at University Malaya.
07:30We're basically utilising AI, if you like,
07:33to basically help us with smarter drug selection, smarter drug screening.
07:37So, there's already been a lot of work that's gone on in the lab.
07:40There's a lot of work that's gone on in the AI and bioinformatics sphere.
07:44And now we're translating that into clinical trials.
07:46And there has also been some pilot studies before this
07:49that showed us that the approach was safe in patients.
07:52And it also gave us a signal that there was anti-cancer activity.
07:55I mean, that's remarkable.
07:57Don't you think that's just science?
08:00You know, it's so wonderful sometimes.
08:01It's very exciting.
08:03And that's why, you know, that's why it's so nice to be able to discuss it today.
08:05Because although, you know, people are, actually people know about repurposing.
08:11Okay.
08:12Because if you remember, you know, aspirin, when it was discovered,
08:18was used for pain relief and then to treat fevers.
08:21But then it's come on now and, you know, it's used for clotting sometimes.
08:27And it's also used, for example, in an anti-cancer indication.
08:33You know, yeah, for some rare colorectal cancers,
08:35it's been shown to work very well in large-scale trials.
08:38So, the whole idea of repurposing is there.
08:41What we're doing is actually, we're going up the next level.
08:45And what we are doing now is multi-purposing.
08:49Multi-purposing.
08:50Multi-purposing.
08:50So, that's a new...
08:51So, the idea is that, you know, we're doing simultaneously these trials
08:55here in Malaysia and then also internationally linking up with partners.
09:01But at the same time, you know, the whole ecosystem is now responding.
09:06So, you've got the science being led by Professor Ivy Chung
09:11in University of Malaya.
09:13University of Malaya, yes.
09:14Right?
09:15And we're bringing together to try and understand, you know, better.
09:19We have lots of indications that Yolanda's mentioned in the papers.
09:22But really, it's pretty special when you're recruiting patients
09:27and then you can study some of the material from the patients
09:30that they want out of them, like the tumours.
09:33You know, you want to get rid of it.
09:34So, you're looking at those tumours and seeing what's the response
09:37once you've treated them.
09:39So, we've got a real opportunity now for Malaysia to, through working with the regulators,
09:47to working with industry, to working with the universities and our clinical work
09:53and so on, to really impact in a way that I think can reach out to ASEAN,
09:59to other countries, you know, where you can't afford treatments anymore sometimes.
10:03Right.
10:03Okay, so, let's talk a little bit about affordability in a little while.
10:08But you mentioned something about multi-purposing.
10:11And in the beginning of our conversation, you mentioned the word permissive,
10:16which I thought was quite interesting.
10:17The environment in Malaysia is conducive, it allows for, it's a permissive environment.
10:23Can we talk a little bit about that?
10:24Why it's important that there be a permissive environment?
10:28What does that entail?
10:30And I'm asking, I think, specifically about the regulatory pathway,
10:33which I can only imagine is far more difficult,
10:36not just in repurposing drugs, but multi-purposing drugs as well.
10:42Shall I kick off?
10:44Because, look, I think, because the, for me, what's clear is that
10:51if the overall objectives are to reach people,
10:55in other words, to have access and affordability,
10:57and if the government has set the frame,
11:01the Madani government, you know, Prime Minister,
11:04they've set the frame, they want to achieve this,
11:06then the institutions are pulling together to support this,
11:11whether it's academia, whether it's the regulatory agencies,
11:14everyone is working together.
11:15So if one has the opportunity to provide ideas to say,
11:20look, or, you know, interventions to say,
11:22look, let's try this, you know, let's work together,
11:24it's amazing the response here.
11:27Because, you know, we're not here to satisfy shareholders' profits,
11:33we're here to impact on people.
11:36Yeah, absolutely.
11:37And I think also because in Malaysia we have the new Industrial Master Plan 2030.
11:40Oh, yeah.
11:41So diagnostics and therapeutics are actually two out of the five key pillars.
11:45And so actually there's this whole of, you know,
11:48government approach where Ministry of Health,
11:50together with Ministry of Higher Education,
11:52Ministry of Science and Technology,
11:53and also, you know, Miti,
11:55Ministry of International Trade and Investment,
11:57they're really focused on wanting to accelerate
11:59the pharmaceutical development, the drug development pathway.
12:02So repurposing, I think, is, you know,
12:05a good low-hanging fruit for Malaysia
12:06because we already also have very good generic drug companies
12:09like Duopharma, Pharma Niaga.
12:11And if you go to Europe, actually it's quite difficult sometimes
12:14for our academic colleagues to find pharmaceutical companies
12:17that are actually genuinely interested in repurposing.
12:20But in Malaysia, this is something that the pharmaceutical companies
12:23are actually very open to
12:24because they also see that repurposing
12:27can potentially create increased opportunities
12:30for existing drugs in their portfolio.
12:33And also we have a population of 700 million in ASEAN.
12:36And for the majority of these patients,
12:38they don't have access to cancer immunotherapy,
12:41which might be 15,000 ringgit per injection.
12:44They don't have access to CAR-T cell therapy,
12:46which may be half a million USD.
12:49So I think this is where, you know,
12:51Malaysia actually has a very strategic advantage
12:53when it comes to the policy framework,
12:55the regulatory framework and also the industry perspective.
12:59I was just about to ask you why it's important
13:01that drug repurposing,
13:04why is drug repurposing relevant for countries like ASEAN?
13:08Can you maybe expand a little bit on that,
13:10particularly from the perspective of cancer care?
13:13Why is it that not only Malaysia but ASEAN
13:18and maybe Malaysia can be the kind of centre point
13:22or the hub, so to speak, the regional hub?
13:24Yeah, so I mean, ASEAN unfortunately has one of the highest
13:28out-of-pocket toxicity, financial toxicity issues
13:31throughout ASEAN.
13:32So many patients basically have to pay out-of-pocket
13:36for certain drugs, certain medications,
13:39particularly when it comes to cancer care.
13:40And although we have a very good government sector
13:43and when it comes to surgery, etc.,
13:45there are certain treatments like cancer immunotherapy
13:48that are actually very, very expensive.
13:49So the majority of patients, cancer patients,
13:54in Malaysia and ASEAN, if they're in the government sector,
13:57it's a real challenge getting access to these cutting-edge drugs.
14:02Often they may be able to access them through a clinical trial,
14:05but that's not something that everybody will be eligible for.
14:09So I think this is an opportunity where looking at more affordable
14:12drug development is obviously vital,
14:15and to also do it in Malaysia.
14:17Because in Malaysia, we have a very good clinical trial ecosystem.
14:20So there's been a lot of work done by Clinical Research Malaysia
14:23and our Ministry of Health to really build a strong ecosystem
14:26when it comes to clinical trial delivery.
14:29And I think over the last 10 years,
14:30there's about 2,500 clinical trials
14:33that have been run in Malaysia.
14:35And that's so amazing,
14:36because essentially it's given cancer patients options
14:39where normally they may not have had treatment options
14:42available to them.
14:43And it's also been a source of revenue generation for the country.
14:46So it's brought in about 1 billion ringgit
14:49or more than 1 billion ringgit
14:50in terms of foreign direct investment from these studies.
14:53But to date, most of these studies are actually pharma-led studies.
14:57So we're actually doing other people's clinical trials
14:59to get drugs registered in that method.
15:03Whereas here, we're also talking about
15:04our own homegrown trials in Malaysia,
15:07developing our own investigator-initiated research
15:10with repurposed drugs in Malaysia,
15:12in our own patient population.
15:15Wow, that's amazing.
15:15We have the capacity for that.
15:17I didn't realise we had.
15:18How do you see it,
15:19the importance of drug repurposing in ASEAN?
15:234 euro.
15:25Or 4...
15:25Sorry, 4 ringgit.
15:261 euro for a daily dose for artesunate.
15:32I mean, you know, the concept is so novel in terms of access
15:38that we would like to take this forward so quickly
15:42for the whole of ASEAN.
15:43Because wherever you look,
15:45whenever there's urbanisation,
15:46wherever there's development,
15:47wherever there's growth,
15:48the diseases join an increase as well.
15:52Whether it's cancers,
15:54you're seeing increased colorectal cancer,
15:55for example,
15:56one of our trials is for this,
15:58in Malaysia,
15:59but also more widely,
16:00wherever there is development.
16:02And yet the solutions are lagging behind
16:05or are behind paywalls.
16:08You can't afford it.
16:09So we, I mean,
16:12I think our role is to work
16:15with the highest standards of science,
16:16the scientific credibility
16:18with our partners in academia,
16:21but to really make that access
16:24and affordability part
16:25immediately translatable
16:27through the best clinical research.
16:30And what you see here in Malaysia
16:32is the capacity, as you said.
16:34You've got a joined up pipeline
16:36from University of Malaya
16:38to clinical research Malaysia
16:40through to, you know,
16:42the populations reaching out.
16:45And actually one of the key components
16:47is our patient advocacy groups.
16:49So actually they've really been behind
16:51driving a lot of the work
16:52around drug repurposing.
16:53And I think Malaysia's just got
16:55so many passionate,
16:56amazing patient advocates
16:57who essentially actually are very much
16:59partners in this repurposing journey.
17:02So all the clinical trials
17:03that we have talked about,
17:04they've been co-developed
17:05and co-designed with patients
17:07very much at the heart of it.
17:08And we're not just looking at cancer,
17:10we're also looking at rare diseases.
17:11And I think this is also
17:13a very opportune timing
17:14because Malaysia has just come up
17:16with its national framework
17:17or policy for rare diseases.
17:19Yes, that's right.
17:20And with rare diseases,
17:21you know, again,
17:22it's also often heartbreaking
17:23for many of these families
17:24because either treatments don't exist
17:26or when they do exist,
17:27they can be 2 million USD,
17:285 million USD to try to access.
17:31So we're working with a group in Europe
17:33called Remedy for All.
17:34And they were basically funded
17:36through EU Horizon grant funding.
17:38And they've set up a very exciting
17:41accelerator platform
17:42where they basically train scientists,
17:45clinical researchers,
17:47and they also bring together
17:47patient advocacy groups and industry
17:49to look at repurposing,
17:51not just for cancer,
17:51but also rare diseases.
17:53And we're building a partnership
17:54with them at University Malaya
17:56and also Ministry of Health Malaysia
17:59so that hopefully Malaysia
18:00can be the ASEAN incubator
18:02or the accelerator for repurposing
18:04and it will be
18:05an international collaboration.
18:07That's exciting, isn't it?
18:09It's fantastic.
18:12You know, Dr. Yolanda mentioned
18:14that, you know,
18:16the model with Remedy for All
18:17and it's funded by the EU and so on.
18:20Now, what do we have at the moment?
18:21Most of what happens now
18:22is that academics do all the work
18:25and then when it reaches the stage
18:28where it's actually,
18:29oh, wow, there's something here,
18:31industry, big, you know,
18:32big industry comes in,
18:33takes over
18:34and then reaps all the benefits.
18:37Yeah, that's part,
18:38and that's the simplification,
18:40but that's the model in a way.
18:42You know, there's public funding
18:44and then, woof,
18:46profits go somewhere.
18:47We're not here for,
18:48we want to put the best ideas
18:51into the benefit for patients
18:54without this, you know,
18:56this huge,
18:57these barriers
18:58and the money standing in the way.
19:02Okay, so what is the vision next?
19:05What's the next step?
19:06So, you've got the clinical trial.
19:08When we have you back in a year
19:11to interrogate the progress,
19:12what would you have liked to see
19:15happen next, Dr. Yolanda?
19:16Yeah, so, I mean,
19:18obviously we need to complete
19:19the clinical trials,
19:20but also what we're doing
19:21is building an ecosystem
19:22because it really does take a village
19:24to, you know,
19:25develop better solutions
19:27for affordable access.
19:29So, with that,
19:30we want to basically expand our network
19:32across Malaysia
19:33and also across ASEAN.
19:34We would like to get more academics
19:36to join us
19:37and to basically unite together
19:39because I think in academia,
19:40often there is this feeling
19:41sometimes of competition.
19:43Walking in silos sometimes.
19:45Exactly, yeah.
19:46So, we're very much
19:46about breaking that down
19:47and we're really pleased, actually,
19:49that we've had such good response
19:50from our academic colleagues
19:51so far in Malaysia
19:53and also some of our ASEAN colleagues,
19:54but also within Ministry of Health.
19:56There's fantastic work
19:57that's been done
19:58at the National Institutes of Health
20:00with Institute of Medical Research,
20:02Institute of Clinical Research.
20:03So, we would really like to,
20:04you know, partner more with them
20:06through University Malaya
20:07and also University Malaysia Sarawak
20:09and basically start to
20:12not just look at artisanate,
20:13but also look at a pipeline.
20:15So, the idea is that
20:16we could actually screen
20:17to develop other drugs as well
20:19that potentially could
20:20have specific indications
20:22for other cancers
20:23and also rare diseases.
20:25So, building this whole
20:26sort of portfolio,
20:27which we hope that eventually
20:28will lead to more clinical trial
20:30options for patients
20:31is where we see this going.
20:33Okay.
20:34And what about you?
20:35What would you consider
20:36a, you know,
20:38a productive year
20:39for IADATA?
20:41I would love to be able
20:45to finish the trials
20:48and then walk into a pharmacy
20:53and say,
20:54by the way,
20:56you know,
20:57we need this treatment
20:58for acute myeloid leukemia
21:00or for HPV.
21:02Do you have any?
21:04And they say,
21:05yes.
21:06And say,
21:07okay,
21:07how much?
21:08And they say,
21:09well, you know,
21:10if you want this whole treatment course,
21:12you know,
21:12it's a few hundred ringgit.
21:14That's it.
21:15So, you know,
21:16for me,
21:16that is the real,
21:18and go to Malaysia,
21:19maybe go to Thailand,
21:21maybe go to Vietnam,
21:22and you can see the same thing
21:23happening at scale.
21:26Because what we do here,
21:27you know,
21:28Malaysia,
21:29let's face it,
21:30I mean,
21:30Malaysia has,
21:31and you live it,
21:33I see it,
21:34it has one of the most
21:35diverse populations.
21:37So,
21:37what you find here,
21:39what we find here,
21:40you know,
21:41you can translate it to India,
21:43you can translate it to Vietnam,
21:44you can translate it to China.
21:46And what I would also like to see,
21:48you know,
21:48China gave us artesanate,
21:50as Yolanda mentioned.
21:51Yes.
21:51You know,
21:52for us to be able to give back something
21:53for that population
21:54and for everyone around,
21:56that really impacts,
21:58in a way that has impacted on malaria,
22:00but for other neglected diseases now,
22:02like cancers,
22:03I mean,
22:04what a thrill.
22:05Can I ask both of you
22:07a philosophical question,
22:09if I may?
22:10Last time when we spoke,
22:11my main takeaway from our conversation
22:13was really about
22:14how much the Global North
22:18had done the gatekeeping
22:20in the area of diagnostics and therapeutics,
22:23and that perhaps the Global South
22:25has some knowledge
22:26and has some agency,
22:27and we should really capitalise
22:30or leverage on that.
22:31What is the main idea
22:34that you're hoping
22:36iData will push forward
22:38and change for global health?
22:41If I may ask you that,
22:43I feel there is so much more
22:45underpinning your work
22:46beyond the clinical work,
22:51the logistical work that you do.
22:52There is a philosophy here
22:54that I think many of us
22:55can jump on board
22:57and it resonates with.
22:58Yolanda?
22:59So I think ultimately
23:01at the heart of it,
23:02I always believe,
23:03in the words of Dr Paul Farmer,
23:05injustice has a cure.
23:07And I think a lot of what we see
23:08happening in the world today,
23:09it's actually systemic structures
23:11that have been set up
23:12to basically focus on profit
23:15above all else.
23:17And often people's lives,
23:19especially those in the Global South,
23:20are deemed to be less important
23:22than patients in the Global North.
23:24And we saw this very much
23:26with the whole COVID-19 vaccine issue as well.
23:30So I think having confidence,
23:33building resilience,
23:33and believing that actually
23:35in the Global South,
23:36we have a lot of agency,
23:37we have a lot of power.
23:39And actually, if we come together,
23:40we are the world majority.
23:41So we should be pushing
23:42for a just solution for all.
23:45Absolutely.
23:46I would also just love
23:49our high-income countries
23:52to benefit from what's happening here.
23:56Because what applies here
23:57applies to there as well.
23:59They're also getting shortchanged.
24:00They don't have the funds
24:02that can afford treatments.
24:04So really quick uptake
24:06from findings made here
24:09through our collaborative work
24:11and through our partners and so on,
24:13should be taken up as well.
24:16Make it global.
24:17Yes, exactly.
24:19Thank you so much
24:19for coming on the show
24:20and telling us what's happening.
24:22Let's hopefully find out
24:24more progress
24:24from the both of you next year.
24:26Thank you very much.
24:27Wonderful.
24:27Thank you so much.
24:28Thank you for your time.
24:29That's all the time
24:29we have for you
24:30on this episode of Consider This.
24:32I'm Melissa Idris,
24:33signing off for the evening.
24:34Thank you so much for watching
24:35and goodnight.
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