Is 92 units of Tresiba (insulin degludec) a high dose?

Is 92 Units of Tresiba a High Dose?

Yes, 92 units of Tresiba (insulin degludec) is considered a high dose, as it exceeds the threshold of 0.5 units/kg/day for most adults, indicating significant insulin resistance and the potential need for therapy intensification.

Understanding Insulin Dosing Thresholds

Insulin dosing is typically evaluated based on weight-adjusted calculations:

• Initial basal insulin dosing typically starts at 0.1-0.2 units/kg/day 1
• Doses exceeding 0.5 units/kg/day suggest significant insulin resistance 1
• Doses approaching 1.0 units/kg/day strongly indicate the need for therapy intensification 1

For context, a 92-unit dose would be considered high for most adults:

• For a 70 kg person: 92 units = 1.31 units/kg/day
• For a 100 kg person: 92 units = 0.92 units/kg/day

Clinical Implications of High Insulin Doses

Signs of Overbasalization

When basal insulin doses exceed 0.5 units/kg/day, clinicians should evaluate for potential overbasalization, which may be indicated by:

• Large bedtime-morning glucose differentials (≥50 mg/dL)
• Hypoglycemic episodes (especially nocturnal)
• High glucose variability 1

Need for Treatment Modification

High basal insulin doses suggest:

1. Consider adding prandial insulin: When basal insulin exceeds 0.5 units/kg/day, especially as it approaches 1.0 units/kg/day, adding mealtime insulin coverage should be considered 1

2. Consider alternative approaches: Adding a GLP-1 receptor agonist or SGLT2 inhibitor may help improve glycemic control while potentially reducing insulin requirements 1, 2

3. Evaluate insulin resistance: High insulin requirements may indicate significant insulin resistance requiring additional interventions 1

Advantages of Tresiba for Higher Doses

While 92 units is a high dose, Tresiba has some characteristics that may be beneficial for patients requiring larger insulin doses:

• Extended duration of action: >42 hours, allowing for stable glucose control 3, 4
• Lower day-to-day variability: More consistent effect compared to other basal insulins 4, 5
• Available in U-200 formulation: For patients requiring large volumes of insulin, the concentrated formulation (200 units/mL) reduces injection volume 1

Monitoring and Safety Considerations

With high insulin doses like 92 units of Tresiba, special attention should be paid to:

• Hypoglycemia risk: While Tresiba may have a lower risk of nocturnal hypoglycemia compared to other basal insulins, high doses still warrant careful monitoring 4, 6
• Cardiovascular risk: Some research has raised questions about potential cardiovascular effects with insulin degludec, though this remains under investigation 7
• Cost considerations: Higher insulin doses increase treatment costs, which may affect adherence 1

Practical Recommendations

For patients on 92 units of Tresiba:

• Regularly monitor fasting and postprandial glucose levels
• Calculate the weight-based dose to determine if it exceeds 0.5-1.0 units/kg/day
• Consider therapy intensification if glycemic targets aren't being met
• Evaluate for insulin resistance and consider additional interventions
• If using U-100 formulation, consider switching to U-200 to reduce injection volume

Remember that insulin requirements vary significantly between individuals, and what constitutes a "high" dose must be interpreted in the context of the patient's weight, insulin sensitivity, and overall clinical picture.