The Unique Feature of the Israeli Type 2 Diabetes Guideline

Jay H. Shubrook, DO; Baruch Itzhak, MD


July 26, 2018

Jay H. Shubrook, DO: Hello, I am Jay Shubrook, Family Physician and Professor at Touro University California. We are presenting here from the 78th American Diabetes Association Scientific Sessions in Orlando, Florida. I am here today with Dr Baruch Itzhak, who is a specialist in family medicine and a diabetologist in the primary care setting in northern Israel. We have a really interesting topic to talk about today. In the United States, there are many different guidelines for diabetes. Right now, we have a little bit of a guideline controversy because the guidelines do not all agree with each other. For me, this was really a great opportunity to learn about other guidelines. What are the guidelines that you follow in Israel?

Baruch Itzhak, MD: We are following the Israeli national plan for the prevention and treatment of diabetes that was developed by the Israel National Council of Diabetes.[1] The [recommendations in the guideline] are actually based on the body mass index (BMI) of the patients [with 3 BMI ranges]. First strategies, of course, are lifestyle management and then metformin. As a second line, there are three possibilities for treating patients according to their BMI. For example, one group includes patients with a BMI between 27 and 30 kg/m2. The other group includes patients with a BMI between 30 and 35 kg/m2; the third group includes patients with a BMI of ≥ 35 kg/m2. We are usually using the newer medications. We also have in our guidelines the possibility to take into consideration economic problems. We can also use less expensive oral medications as a possibility.

They are very clear guidelines. The general practitioners (GPs) and specialists in our country are using the guidelines according to what patient factors they have in front of them.

Shubrook: We do not have many people in the US with type 2 diabetes with a BMI in the lower range. What would happen for someone with a BMI between 27 and 30?

Itzhak: The consensus is that a patient with a BMI between 27 and 30, after getting metformin as a first choice, can [then be given in] combination [with metformin] either a dipeptidyl peptidase-4 (DPP-4) inhibitor or a sodium-glucose co-transporter-2 (SGLT2) inhibitor. There is also the possibility of using a glucagon-like peptide-1 (GLP-1) receptor agonist in some patients.

If [the patient has a] BMI of > 30, then, of course, the first choice should be either a GLP-1 receptor agonist, as an addition to metformin, or an SGLT2 inhibitor, again as an addition to metformin. Then we can consider also the possibility for a DPP-4 inhibitor.

If [the patient has a] BMI > 35, we have to consider bariatric surgery.

Shubrook: That is an important distinction, because there are a number of organizations that recommend metabolic surgery for the treatment of type 2 diabetes. You actually highlight that for those in the highest BMI.

Itzhak: Yes, absolutely.

Shubrook: How are these guidelines adopted within your country? Are they adopted differently by specialists and primary care clinicians?

Itzhak: These guidelines are well adopted throughout the country by both GPs and specialists. When GPs are treating diabetes, generally they are more conservative than specialists in the way of thinking of how to treat the patient. [GPs] view the patient [in the context of] his family, his needs, and his situation. Usually, treatments are personalized based on [his life context including] age, duration of disease, comorbidities, economic status, and, of course, compliance. It is very important for the patient to see how he can manage with our recommendations.

The overview is more general, but we are looking to treat the patient in a very personal way using recommended dosing guidelines. Sometimes we also need to change our way of thinking because, as GPs, we see patients a lot and we should [be able to determine] the patient's compliance with treatment.

Shubrook: We know that the primary care setting presents the best opportunity to individualize care because you know the patient and their family. When you take those factors into account, it sometimes sounds like you may loosen care because there are other factors that might harm the ability to get tighter control. Is that correct?

Itzhak: That is correct.

Shubrook: The American Diabetes Association (ADA) publishes annual standards for diabetes care. Is there any interface between the ADA guidelines and your guidelines in practice?

Itzhak: In practice, we very strongly endorse personalized therapy. For example, it is very important that an older, frail patient with a short life expectancy is treated more conservatively than a younger patient. You can see the difference between the way of thinking of a specialist or the diabetologist and a family physician. The family physician is more conservative. He is waiting to see what happens with the new medications, how [they] may influence the patient, and the side effects of those new medications because the family physician is treating many diseases. He is not so focused on getting the target A1c as low as possible.

Conservatively, we endorse the recent guidance from the American College of Physicians.[2] We are talking about being more relaxed, more conservative, and more flexible about the patient targets.

Regarding treatment, specialists [tend to be] more aggressive. They follow the ADA recommendations, including the new ADA recommendation about considering cardiovascular risk factors,[3] highlighting the importance of immediately treating patients who are at higher risk with the new medications.

Shubrook: What I heard today is that, within Israel, you have specific guidelines, which, like most guidelines, are focused on individualization of care. However, there is a segmentation by BMI, which we think probably has different pathophysiology in diabetes. The guidelines also highlight the importance of individualized therapies for patients. Thank you for coming today and sharing this.


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