Endocrine, Renal and GI: Diabetes, Ramadan and the Rest of Medicine

Weight and where it sits

This is the second medicine domain, with cardio-respiratory and infection and haematology. It carries about 15 items on a 150-item paper in our planning mix. The number is ours; the regulators publish none at this level. The heaviest single topic is diabetes, which appears in five subtopics here and returns in obstetrics, paediatrics and surgery.

What is tested

Diabetes and metabolism

Type 2 diagnosis and stepwise treatment, type 1 and insulin regimens, DKA and hyperosmolar hyperglycaemic state, hypoglycaemia and sick-day rules, chronic complications (retinopathy, nephropathy, neuropathy, diabetic foot), obesity and metabolic syndrome, and diabetes with Ramadan fasting.

Endocrine

Hypothyroidism, hyperthyroidism and thyroid nodules; adrenal disorders (Cushing, Addison, phaeochromocytoma, primary aldosteronism); vitamin D deficiency, osteoporosis and calcium disorders.

Renal and acid-base

Acute kidney injury, chronic kidney disease with KDIGO staging and complications, sodium and potassium disorders, and acid-base disorders.

Gastrointestinal and hepatology

Peptic ulcer disease, Helicobacter pylori and GERD; upper and lower gastrointestinal bleeding; inflammatory bowel disease and coeliac disease; viral hepatitis B and C; cirrhosis and NAFLD; pancreatitis and gallstone disease.

Guideline points to hold

Diabetes in Ramadan: medication adjustments

• Metformin: usually no change; take with iftar, with three-times-daily regimens split around the meals.
• Sulfonylureas: prefer second-generation agents such as gliclazide and glimepiride, taken at iftar; avoid glibenclamide; reduce the dose if control is good.
• SGLT2 inhibitors: no adjustment, taken with iftar, but not started just before Ramadan because of volume depletion and euglycaemic ketoacidosis.
• DPP-4 inhibitors and GLP-1 agonists: no adjustment, provided GLP-1 titration finished 2 to 4 weeks earlier.
• Basal insulin in type 2: give at iftar and reduce the dose by 15 to 30%.
• Type 1 on analogue basal-bolus: basal reduced 30 to 40% and taken at iftar, suhoor rapid-acting dose reduced 30 to 50%, pre-lunch dose omitted. Check ketones if glucose is above 14.0 mmol/L, and break the fast if ketones exceed 0.6 mmol/L.

How renal and acid-base items are built

Renal and electrolyte stems rarely ask for a fact. They give a set of results and ask you to name the disturbance, the cause or the first action. Work in a fixed order. First, is the problem acute or chronic, and is it pre-renal, intrinsic or post-renal? Second, what do the electrolytes and the acid-base picture say together? Third, which drug or condition in the history explains it? A diabetic on an ACE inhibitor with a vomiting illness and a rising creatinine is an acute kidney injury question and a medication-review question at once. The sick-day rules that appear in the diabetes subtopic are the same logic, applied to a patient who is unwell and not eating: which tablets to pause, when to check ketones, and when to seek help.

Gastrointestinal and liver items follow a similar pattern. Peptic ulcer and bleeding stems ask about resuscitation first and endoscopy second. Inflammatory bowel disease and coeliac disease stems ask for the test that confirms, then the treatment that suits the severity. Hepatitis stems give a serology panel and ask what it means. Cirrhosis stems ask about the complication in front of you, such as ascites, variceal bleeding or encephalopathy. In each, learn the decision order and the one or two discriminating features.

Three typical traps

1. Units. Gulf laboratories use both SI and conventional units. A glucose of 14 means something very different in mmol/L and mg/dL. Read the unit before the number, and convert in your head when the stem mixes them.
2. Treating the potassium before the ECG. The hyperkalaemia emergency sequence starts with membrane protection when the ECG is abnormal. A stem with a high potassium and a normal ECG asks a different question.
3. Applying a Ramadan rule to the wrong risk group. The category decides whether the advice is "do not fast", "fast with adjustment" or "no change". Place the patient in the risk category before choosing the drug adjustment.

How to revise it

1. Learn the diabetes spine first: diagnosis, stepwise treatment, DKA and hypoglycaemia. Then add Ramadan as an overlay on the same drugs.
2. Build one electrolyte sheet covering sodium and potassium, with causes, ECG signs and the first three actions.
3. Memorise KDIGO staging logic, not only the names, since stems give eGFR and albuminuria and ask for the stage or action.
4. Do hepatology by pattern: viral hepatitis markers, cirrhosis complications, NAFLD risk. Pattern recognition beats detail here.
5. Use mixed sets in week 3 of the study plan and revisit this domain before every mock.

Cross-links: diabetes in pregnancy is in obstetrics, DKA in children in paediatrics, and the diabetic foot in surgery. See also the high-yield list for the numbers table.