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

Role of Tresiba (Insulin Degludec) in Diabetes Treatment

Tresiba (insulin degludec) is a long-acting basal insulin analog indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus, particularly when oral agents and/or GLP-1 receptor agonists fail to achieve glycemic targets. 1, 2

Indications and Clinical Position

• Recommended for initiation when:

  • HbA1c levels are ≥9%
  • Blood glucose levels are ≥300-350 mg/dL
  • HbA1c levels are 10-12% with symptomatic hyperglycemia 1

• Not recommended for treatment of diabetic ketoacidosis 2

Unique Properties of Tresiba

• Ultra-long-acting profile with duration of action >42 hours 3
• Flat, stable glucose-lowering effect with less day-to-day variability compared to insulin glargine 3
• Available in two concentrations:
  • 100 units/mL (U-100): 3 mL prefilled pen and 10 mL vial
  • 200 units/mL (U-200): 3 mL prefilled pen (beneficial for patients requiring large insulin doses) 2, 3

Dosing and Administration

Initial Dosing

• Insulin-naïve patients: Start with 10 units once daily or 0.1-0.2 units/kg/day 1
• For pediatric patients requiring <5 units daily, use U-100 vial 2

Administration Schedule

• Adults: Inject subcutaneously once daily at any time of day 2
• Pediatric patients: Inject subcutaneously once daily at the same time every day 2
• Unique flexibility: Studies show potential for adjusting injection time without compromising glycemic control 4

Dose Titration

• Adjust dose every 3-4 days based on blood glucose monitoring 1
• Target fasting glucose levels of 80-130 mg/dL 1

Combination Therapy Considerations

• Maintain metformin when initiating Tresiba 1
• Consider discontinuing sulfonylureas and DPP-4 inhibitors when starting combination injectable therapy 1
• For patients requiring large insulin doses, consider adding thiazolidinediones or SGLT2 inhibitors to improve control and reduce insulin requirements 1
• Can be used as the basal component in combination with rapid-acting insulin analogs 1
• Degludec plus liraglutide shows greater durability of glycemic effect compared to basal insulin alone 1

Clinical Benefits

• Similar glycemic control to insulin glargine but with lower risk of nocturnal hypoglycemia in patients with type 1 or 2 diabetes 3
• Prospective observational studies show significantly lower rates of overall, nonsevere, severe, and nocturnal hypoglycemia when switching from other basal insulins 5
• Improved treatment satisfaction reported by patients 5

Safety Considerations and Warnings

Important Precautions

• Never share pens, syringes, or needles between patients 2
• Increased risk of hypoglycemia with changes in insulin regimen, concomitant drugs, meal patterns, or physical activity 2
• Requires close monitoring in patients with renal or hepatic impairment 2
• Risk of medication errors: Always check insulin labels before injection 2

Potential Concerns

• Some data suggest potential increased cardiovascular risk compared to insulin glargine, though this requires further investigation 6
• Limited data on use during pregnancy; best avoided in pregnant women 6
• Risk of confusion with the 200 units/mL concentration 6

Practical Administration Tips

• Inject subcutaneously into thigh, upper arm, or abdomen 2
• Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis 2
• DO NOT transfer insulin degludec from pen into syringe as this can result in overdose and severe hypoglycemia 2

Tresiba represents an advancement in basal insulin therapy with its ultra-long duration of action and flexible dosing schedule, potentially improving adherence for patients with unpredictable schedules or those who find rigid insulin scheduling burdensome.