What is the recommended use and dosing of insulin degludec (insulin degludec) for type 1 and type 2 diabetes mellitus?

Insulin Degludec: Recommended Use and Dosing in Diabetes Mellitus

Insulin degludec is recommended as a once-daily basal insulin for both type 1 and type 2 diabetes, with primary advantages of reduced nocturnal hypoglycemia risk and flexible dosing schedule compared to other basal insulins. 1, 2

General Characteristics and Indications

• Insulin degludec is an ultra-long-acting insulin analog with a duration of action >42 hours and a flat, stable glucose-lowering profile 2
• Available in two concentrations: U-100 and U-200, with the U-200 formulation beneficial for patients requiring large volumes of basal insulin 1
• In type 1 diabetes, insulin degludec must always be used concomitantly with short-acting insulin 1
• In type 2 diabetes, it can be used as part of a basal-bolus regimen or as a basal-only addition to oral medications 3

Dosing Recommendations

Type 1 Diabetes:

• Starting dose for insulin-naïve patients: Approximately one-third to one-half of the total daily insulin dose 1
• Initial calculation: 0.2 to 0.4 units/kg of body weight can be used to calculate total daily insulin dose, with approximately half as basal insulin degludec 1
• When switching from other basal insulins:
  • Adults: Start at the same unit dose as the previous total daily long or intermediate-acting insulin 1
  • Pediatric patients (≥1 year): Start at 80% of the previous total daily long or intermediate-acting insulin dose to minimize hypoglycemia risk 1

Type 2 Diabetes:

• Starting dose for insulin-naïve patients: 10 units once daily 1
• When switching from other basal insulins: Same unit dose as the previous total daily long or intermediate-acting insulin for adults 1

Administration Guidelines

• Administer subcutaneously once daily at any time of day in adults 1
• In pediatric patients, administer at the same time every day 1
• Dose titration should be individualized based on metabolic needs, blood glucose monitoring, and glycemic targets 1
• Recommended time between dose increases is 3-4 days 1
• For missed doses in adults: Inject the daily dose upon discovery, ensuring at least 8 hours between consecutive injections 1
• For missed doses in pediatric patients: Contact healthcare provider for guidance and monitor blood glucose more frequently until the next scheduled dose 1

Comparative Efficacy and Safety

• Insulin degludec achieves similar glycemic control to insulin glargine in both type 1 and type 2 diabetes 2, 4
• Key advantage: Significantly lower risk of nocturnal hypoglycemia compared to insulin glargine:
  • 25-58% reduction in nocturnal hypoglycemia in type 1 diabetes 4, 5
  • 25% reduction in nocturnal hypoglycemia in type 2 diabetes 5
• Less within-patient day-to-day variability in glucose-lowering effect compared to insulin glargine 2
• Allows for flexible dosing schedule without compromising glycemic control 2, 6

Special Considerations

• World Health Organization guidelines for resource-limited settings recommend human insulin as first-line insulin therapy, with long-acting analogs like degludec considered only for patients with frequent severe hypoglycemia on human insulin 3
• Never share insulin degludec FlexTouch pens, needles, or insulin syringes between patients due to risk of bloodborne pathogen transmission 1
• Dosage adjustments may be needed with changes in physical activity, meal patterns, renal/hepatic function, or during acute illness 1
• Available delivery devices:
  • FlexTouch prefilled pen (U-100): delivers doses in 1-unit increments up to 80 units per injection 1
  • FlexTouch prefilled pen (U-200): delivers doses in 2-unit increments up to 160 units per injection 1
  • Multiple-dose vial (U-100): for patients requiring less than 5 units daily 1

Contraindications and Warnings

• Contraindicated during episodes of hypoglycemia 1
• Contraindicated in patients with hypersensitivity to insulin degludec or any excipients 1
• Changes in insulin regimen may affect glycemic control and predispose to hypoglycemia or hyperglycemia 1
• Repeated injections into areas of lipodystrophy or localized cutaneous amyloidosis may result in hyperglycemia 1