What is the role of Tresiba (insulin degludec) in treating diabetes?

Role of Tresiba (Insulin Degludec) in Treating Diabetes

Tresiba (insulin degludec) is an ultra-long-acting basal insulin analog that serves as an effective option for glycemic control in patients with type 1 and type 2 diabetes, with particular benefits in reducing nocturnal hypoglycemia and allowing flexible dosing schedules compared to other basal insulins.

Pharmacological Properties and Advantages

Insulin degludec has several distinctive characteristics:

• Ultra-long duration of action (>42 hours) 1
• Flat, stable glucose-lowering profile 1
• Less within-patient day-to-day variability compared to insulin glargine 1
• Available in two concentrations: 100 units/mL (U-100) and 200 units/mL (U-200) 2

Indications

Tresiba is FDA-approved to improve glycemic control in:

• Patients with type 1 diabetes mellitus (age 1 year and older)
• Patients with type 2 diabetes mellitus (age 1 year and older) 2

Limitation of use: Not recommended for treating diabetic ketoacidosis 2

Place in Diabetes Treatment Algorithm

Type 2 Diabetes

• Basal insulin (including degludec) is typically initiated when oral agents and/or GLP-1 receptor agonists fail to achieve glycemic targets 3
• Consider starting basal insulin when:
  • HbA1c levels ≥9% 3
  • Blood glucose levels ≥300-350 mg/dL 3
  • HbA1c levels 10-12% with symptomatic hyperglycemia 3

Type 1 Diabetes

• Essential component of treatment as part of a basal-bolus regimen
• Can be used as the basal component in combination with rapid-acting insulin analogs 3

Dosing and Administration

• Initial dosing:

  • Insulin-naïve patients: 10 units once daily or 0.1-0.2 units/kg/day 3, 2
  • For patients switching from other insulins: Individualize based on previous insulin requirements

• Administration:

  • Inject subcutaneously into thigh, upper arm, or abdomen 2
  • In adults: Can be administered once daily at any time of day 2
  • In pediatric patients: Should be administered at the same time every day 2
  • Rotate injection sites to reduce risk of lipodystrophy 2

• Dose titration:

  • Adjust dose every 3-4 days based on blood glucose monitoring 4
  • Target fasting glucose: 80-130 mg/dL 4

Clinical Benefits

1. Reduced Hypoglycemia Risk:

   • Lower rates of nocturnal hypoglycemia compared to insulin glargine 1, 5
   • Significant reduction in overall, nonsevere, severe, and nocturnal hypoglycemia when switching from other basal insulins 5

2. Flexible Dosing Schedule:

   • Unlike other basal insulins that require strict timing, degludec can be administered at different times from day to day without compromising glycemic control 6
   • This flexibility may improve treatment adherence in patients with unpredictable schedules 6

3. Available in Higher Concentration:

   • U-200 formulation allows administration of larger doses with smaller injection volumes, beneficial for patients requiring large insulin doses 2, 1

4. Combination Options:

   • Available as a fixed combination with rapid-acting insulin aspart (Ryzodeg®) 1
   • When used in combination injectable therapy, degludec plus liraglutide (IDegLira) shows greater durability of glycemic effect compared to basal insulin alone 3

Special Considerations and Precautions

1. Safety Concerns:

   • Never share pens, syringes, or needles between patients 2
   • Monitor for hypoglycemia, particularly when changing insulin regimens 2
   • Risk of medication errors: Ensure patients check insulin labels before injection 2
   • Potential hypersensitivity reactions 2

2. Cardiovascular Safety:

   • Some studies have raised questions about potential cardiovascular risks compared to insulin glargine 7
   • Monitor patients with cardiovascular risk factors closely

3. Concomitant Medications:

   • When initiating combination injectable therapy with degludec, metformin should be maintained while sulfonylureas and DPP-4 inhibitors are typically discontinued 3
   • For patients requiring large insulin doses, consider adding thiazolidinediones or SGLT2 inhibitors to improve control and reduce insulin requirements 3

Practical Implementation

1. Switching from Other Basal Insulins:

   • When switching from once-daily basal insulin, start degludec at the same unit dose
   • When switching from twice-daily basal insulin, reduce the total daily dose by 20-30%
   • Monitor blood glucose closely after switching and adjust dose as needed

2. Monitoring:

   • Regular self-monitoring of blood glucose
   • HbA1c testing every 3 months to assess overall glycemic control

3. Patient Education:

   • Proper injection technique and site rotation
   • Recognition and management of hypoglycemia
   • Importance of carrying quick-acting carbohydrates for hypoglycemia treatment

In conclusion, Tresiba represents an important advancement in basal insulin therapy with its ultra-long duration of action, flexible dosing schedule, and reduced risk of nocturnal hypoglycemia, making it a valuable option for patients with both type 1 and type 2 diabetes who require basal insulin therapy.