What is the proper usage of Ryzodeg (insulin degludec) in patients?

How to Use Ryzodeg in Patients

Ryzodeg (insulin degludec/insulin aspart) should be initiated at 10 units once daily with the main meal, with subsequent dose adjustments of 2-4 units weekly based on blood glucose monitoring until target fasting glucose levels are achieved.

Understanding Ryzodeg

Ryzodeg is a combination insulin product containing:

• Insulin degludec: An ultra-long-acting basal insulin with a half-life of 17-21 hours and duration of action >42 hours
• Insulin aspart: A rapid-acting insulin for mealtime coverage

This combination provides both basal insulin coverage and prandial (mealtime) coverage in a single injection, making it a convenient option for patients requiring both components.

Indications for Ryzodeg

Ryzodeg is appropriate for:

• Patients with type 2 diabetes who have inadequate glycemic control on oral medications
• Patients transitioning from basal insulin who need additional prandial coverage
• Patients who would benefit from a simplified insulin regimen with fewer daily injections

Dosing and Administration

Initial Dosing

• For insulin-naïve patients: Start with 10 units once daily with the largest meal 1, 2
• For patients switching from basal insulin: Consider starting with the same total daily dose as the previous basal insulin
• For patients with significant hyperglycemia (HbA1c ≥10% or blood glucose ≥300 mg/dL): Consider higher initial doses (0.2-0.3 units/kg/day) 2

Dose Titration

• Adjust dose by 2-4 units once or twice weekly based on fasting blood glucose levels 1, 2
• Target fasting glucose of 90-130 mg/dL (or individualized targets based on patient characteristics)
• For older adults or those at high risk of hypoglycemia, consider a more conservative target of 90-150 mg/dL 2

Timing of Administration

• Administer once daily with the main meal (typically the largest meal of the day)
• The timing can be flexible but should be consistent from day to day when possible
• If a dose is missed, administer with the next main meal of that day and resume the regular dosing schedule the following day

Monitoring and Adjustments

Blood Glucose Monitoring

• Check fasting blood glucose daily during initial titration
• Consider additional pre-meal checks to assess 24-hour control
• Use the following algorithm for dose adjustments:
  • Fasting glucose consistently >130 mg/dL: Increase by 2 units
  • Fasting glucose 70-90 mg/dL: Consider decreasing by 2 units
  • Fasting glucose <70 mg/dL or hypoglycemic episodes: Decrease by 4 units

Hypoglycemia Management

• Treat hypoglycemia (glucose <70 mg/dL) with 15-20g of fast-acting carbohydrate
• Recheck blood glucose after 15 minutes and repeat treatment if still low 2
• Prescribe glucagon for emergency hypoglycemia management
• If recurrent hypoglycemia occurs, reduce the Ryzodeg dose

Special Considerations

Advantages of Ryzodeg

• Reduced number of daily injections compared to basal-bolus regimens
• Lower risk of nocturnal hypoglycemia compared to other insulin regimens 3, 4
• More flexible dosing window than traditional premixed insulins
• Available in prefilled pens to minimize dosing errors 1

Potential Limitations

• Less flexibility in adjusting the ratio of basal to bolus insulin compared to separate injections
• May not provide adequate coverage for patients with highly variable insulin requirements
• Not suitable for patients requiring multiple daily injections for optimal glycemic control

Concomitant Medications

• Continue metformin when initiating Ryzodeg if not contraindicated 1, 2
• Consider discontinuing sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists on an individual basis 1
• For patients with suboptimal control despite optimized Ryzodeg, consider adding an SGLT-2 inhibitor 1

When to Consider Alternative Regimens

Consider switching from Ryzodeg to a more intensive insulin regimen if:

• HbA1c remains above target despite optimized Ryzodeg dosing
• Patient experiences significant postprandial hyperglycemia at meals other than the main meal
• Patient requires more flexibility in insulin dosing based on carbohydrate intake

In these cases, transition to a basal-bolus regimen with separate basal insulin (such as insulin degludec alone) and rapid-acting insulin before meals may be appropriate 1, 2.

Common Pitfalls and How to Avoid Them

1. Inadequate dose titration: Ensure regular dose adjustments based on blood glucose patterns rather than fixed doses.

2. Inconsistent timing of administration: Educate patients on the importance of consistent timing with meals.

3. Relying solely on fasting glucose: Monitor both fasting and postprandial glucose to ensure adequate coverage.

4. Failure to adjust for exercise or illness: Teach patients how to adjust doses during periods of increased activity or illness.

5. Improper injection technique: Ensure patients rotate injection sites and use proper technique to avoid lipohypertrophy and ensure consistent absorption.