What adjustments should be made to the insulin regimen for a type 2 diabetic patient on Tresiba (insulin degludec) 12 units at bedtime with persistent hyperglycemia?

Management of Persistent Hyperglycemia in Type 2 Diabetes on Tresiba

The insulin regimen should be intensified by increasing the Tresiba dose by 2-4 units twice weekly until fasting blood glucose targets are reached, and adding prandial insulin to address the significantly elevated premeal glucose levels. 1

Current Situation Assessment

The patient is experiencing significant hyperglycemia with premeal glucose readings between 13.2-18.6 mmol/L (238-335 mg/dL) despite being on Tresiba (insulin degludec) 12 units at bedtime. These values are well above target ranges and require prompt intervention to reduce the risk of diabetes-related complications.

Basal Insulin Optimization

1. Increase Tresiba dose:

   • Current dose (12 units) is likely insufficient
   • Increase by 2-4 units twice weekly until fasting glucose reaches target range (typically 4.4-7.2 mmol/L or 80-130 mg/dL) 1, 2
   • Monitor for hypoglycemia during titration and adjust accordingly

2. Maximum basal insulin considerations:

   • Be alert for overbasalization if dose exceeds 0.5 units/kg/day 1, 2
   • Clinical signs of overbasalization include high bedtime-morning glucose differential and hypoglycemia 1

Adding Prandial Insulin Coverage

Given the significantly elevated premeal glucose levels (13.2-18.6 mmol/L), basal insulin alone is unlikely to achieve adequate control. The 2023 ADA guidelines recommend adding prandial insulin when postprandial glucose excursions remain significant 1.

Stepwise approach to adding prandial insulin:

1. Start with a single injection of rapid-acting insulin before the meal with largest glucose excursion (typically dinner) 1

   • Initial dose: 4 units or 10% of the basal dose 1
   • Titrate based on postprandial glucose readings

2. If needed, add a second prandial injection before the meal with the next largest excursion (often breakfast) 1

3. Consider a third injection before the remaining meal if glycemic targets are still not achieved 1

Medication Considerations

1. Maintain metformin if the patient is taking it and has no contraindications 1

2. Consider GLP-1 receptor agonist:

   • ADA 2023 guidelines recommend GLP-1 RAs in combination with insulin for greater efficacy, durability, and reduced hypoglycemia risk 1
   • This combination may be more effective than increasing insulin doses alone

Monitoring and Follow-up

1. Frequent blood glucose monitoring:

   • Monitor fasting and premeal glucose levels daily during dose adjustments
   • Target range: 4.4-7.2 mmol/L (80-130 mg/dL) for fasting glucose

2. Regular follow-up:

   • Reassess medication regimen every 3-6 months 1
   • Adjust therapy based on glucose patterns and A1C results

Common Pitfalls to Avoid

1. Delayed intensification: The 2023 ADA guidelines emphasize that treatment intensification should not be delayed when patients are not meeting glycemic targets 1

2. Overbasalization: Continuing to increase basal insulin without addressing postprandial hyperglycemia is ineffective; if basal dose exceeds 0.5 units/kg/day, prandial coverage is likely needed 1, 2

3. Inadequate titration: Many patients remain on suboptimal insulin doses due to insufficient titration; systematic dose adjustments are essential 1, 2

4. Ignoring patient education: Ensure the patient understands insulin administration, glucose monitoring, and hypoglycemia management

By following this approach, the patient's glycemic control should improve significantly, reducing the risk of diabetes-related complications and improving quality of life.