In the last few years, there have been simply enormous changes in endocrinology and our ability to help people with endocrine diseases. 

 

Glucagon-like peptide-1 and double or triple incretin therapies result in 15–25% weight loss. They improve cardiovascular risk, renal function and possibly neurodegenerative disease. The recognition of obesity as a long-term chronic disease is important and not universally accepted in the UK – but this is essential. We need to push for the more rapid rollout of these treatments.

 

Precision endocrinology is increasingly important. Wiebke Arlt has spearheaded metabolomics in the adrenal field and Niki Karavitaki is doing the same in the field of pituitary disease. For example, Wiebke’s work enables the prediction of adrenal cancer in adrenal incidentaloma with high accuracy. This has hugely important implications for the future of early diagnosis of these tumours.

EXAMPLES OF NEW AND FUTURE DEVELOPMENTS

The following are just a fraction of the recent and forthcoming likely improvements in endocrine science, and in our ability to manage patients with endocrine conditions in a more sophisticated and science-based manner. All these areas are benefiting from rapid progress.

Oncology

In endocrine oncology, we can more accurately predict disease behaviour in thyroid cancer and in neuroendocrine tumours, improving the outlook in these diseases significantly. 

Reproduction

Reproductive endocrinology has seen significant improvement in our understanding of polycystic ovary syndrome (now polyendocrine metabolic ovarian syndrome, see page 17), genetics and the importance of these.

The fields of fertility and the menopause will see further great advances and have already seen some. For example, there is the possibility of patients with premature ovarian failure being able to hold a pregnancy to term, through ovum donation and oestrogen replacement in the first trimester.

Adrenal

The treatment of Cushing’s syndrome with osilodrostat is very effective in reducing cortisol levels. In the UK in particular, we need to make progress in getting acceptance of these treatments, which are unfortunately expensive. Otherwise, we risk lagging behind other countries.

Mild adrenal hypersecretion of cortisol, as seen in mild autonomous cortisol secretion, is increasingly diagnosed. The better delineation of this disease in the future will undoubtedly improve the outlook for these patients. 

We have improved ways of replacing steroids in patients with adrenal insufficiency. These are much better than thrice-daily hydrocortisone, but unfortunately are also expensive.

Also in the adrenal field, we now know that far more patients with hypertension have primary aldosteronism, so we need better screening for people with this curable form of hypertension. In phaeochromocytoma, we now understand that 30–40% of cases are genetic, and better screening for these is important as we move forward.

Pituitary

We can also predict, in some instances, which pituitary tumours will recur. For example, genetic analysis of pituitary tumours causing Cushing’s disease shows an increased risk of the USP8 genotype, which has a higher risk of occurrence. Importantly, this will enable hugely improved surveillance of patients with Cushing’s disease.

In the pituitary field, Mirjam Crist-Crain has also described oxytocin deficiency as a concomitant of some posterior pituitary pathologies. Diagnosis and treatment in this area will become more established. We know, for example, that oxytocin deficiency has a number of effects adversely and psychologically, and improvements in our understanding over the next few years will be very exciting.

Our understanding of the mechanisms behind immune checkpoint inhibitor-induced hypophysitis and adrenalitis will probably also give us better understanding of other forms of pituitary and adrenal disease.

More generally, our growing knowledge of endocrine-disrupting chemicals will be of increasing importance going forward, including with plastics, pesticides and industrial chemicals. Meanwhile, artificial intelligence will doubtless give us better interpretation of pituitary and pancreatic radiology.

Being a pathological optimist helps in life, but optimism is entirely justified when it comes to the future of endocrinology and in particular the future of British endocrinology. Our discipline has an increasing number of world leaders, contributing to the advancement of our knowledge of endocrine disease.

JOHN WASS
Professor of Endocrinology, University of Oxford