At what level of hypoglycemia should Tresiba (insulin degludec) be held?

When to Hold Tresiba (Insulin Degludec) Based on Glucose Levels

Tresiba (insulin degludec) should be held when blood glucose falls below 70 mg/dL (3.9 mmol/L), which is classified as Level 1 hypoglycemia. 1

Classification of Hypoglycemia and Thresholds

The American Diabetes Association classifies hypoglycemia into three levels:

• Level 1: Glucose <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L)
• Level 2: Glucose <54 mg/dL (3.0 mmol/L)
• Level 3: Severe event characterized by altered mental and/or physical status requiring assistance 1

Management Algorithm for Tresiba Based on Glucose Levels

1. Hold Tresiba when glucose <70 mg/dL (3.9 mmol/L)

   • This is the standard threshold for hypoglycemia that correlates with the initial release of counterregulatory hormones 1
   • Modification of insulin regimen is required at this level unless the event is easily explained by other factors (such as a missed meal) 1

2. Reassess insulin regimen when glucose <100 mg/dL (5.6 mmol/L)

   • Consider reassessing the Tresiba dosing regimen when glucose falls below 100 mg/dL to prevent progression to hypoglycemia 1
   • Fasting glucose levels <100 mg/dL are predictors of hypoglycemia within the next 24 hours 1

3. Urgent intervention when glucose <54 mg/dL (3.0 mmol/L)

   • Level 2 hypoglycemia requires immediate treatment and reassessment of insulin dosing 1
   • This level of hypoglycemia is associated with cognitive impairment 1

Special Considerations for Tresiba

Tresiba (insulin degludec) has unique properties that influence hypoglycemia management:

• Ultra-long duration of action (>42 hours) means that hypoglycemic effects can persist longer than other basal insulins 2
• Lower risk of nocturnal hypoglycemia compared to other long-acting insulins like insulin glargine 3, 4
• Less day-to-day variability in glucose-lowering effect than other long-acting insulins 2

Treatment of Hypoglycemia When Using Tresiba

If hypoglycemia occurs while on Tresiba:

1. For conscious patients with glucose <70 mg/dL:

   • Administer 15-20g of fast-acting carbohydrates 1
   • Recheck glucose after 15 minutes
   • Repeat treatment if hypoglycemia persists
   • Once glucose normalizes, consume a meal or snack to prevent recurrence 1

2. For severe hypoglycemia (Level 3):

   • Administer glucagon if the patient is unable to consume carbohydrates 1
   • Seek immediate medical attention

Risk Factors for Hypoglycemia with Tresiba

Be particularly vigilant about holding Tresiba in patients with:

• Recent episodes of hypoglycemia (especially Level 2 or 3) 1, 5
• Impaired hypoglycemia awareness 1
• End-stage kidney disease 1
• Cognitive impairment or dementia 1
• Food insecurity or irregular eating patterns 1, 5
• Age >75 years 1

Prevention of Recurrent Hypoglycemia

After holding Tresiba due to hypoglycemia:

• Consider dose reduction when restarting Tresiba, especially if there is a pattern of hypoglycemia 1
• For patients with recurrent hypoglycemia, consider raising glycemic targets temporarily 1
• Document all hypoglycemic episodes and follow up within 1-2 weeks to assess effectiveness of interventions 5

Common Pitfalls to Avoid

• Failing to adjust Tresiba dose after hypoglycemia: Studies show that 75% of patients do not have their basal insulin dose changed after a hypoglycemic episode 5
• Ignoring mild hypoglycemia: 84% of patients with severe hypoglycemia had a preceding milder episode 5
• Overlooking the ultra-long duration of action: Tresiba's effects persist longer than other basal insulins, so hypoglycemia may recur even after initial treatment 2

By following these guidelines, clinicians can appropriately manage Tresiba administration to minimize the risk of hypoglycemia while maintaining effective glycemic control.