What is the recommended usage and dosing of Tresiba (insulin degludec) for patients with diabetes mellitus?

Tresiba (Insulin Degludec) Usage and Dosing for Diabetes Mellitus

Tresiba (insulin degludec) is a once-daily, ultra-long-acting basal insulin indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus, with a duration of action exceeding 42 hours and less day-to-day variability compared to other basal insulins. 1, 2

General Dosing Instructions

• Tresiba is available in two concentrations: U-100 (100 units/mL) and U-200 (200 units/mL) 1
• For adults, Tresiba can be injected subcutaneously once daily at any time of day 1
• For pediatric patients, Tresiba should be injected at the same time every day 1
• Injection sites include thigh, upper arm, or abdomen, with rotation within the same region recommended to reduce risk of lipodystrophy 1
• No dose conversion is needed between U-100 and U-200 FlexTouch pens as the dose window shows the number of insulin units to be delivered 1

Starting Dose Recommendations

Type 1 Diabetes:

• Recommended starting dose is approximately one-third to one-half of the total daily insulin dose 1
• The remainder should be administered as short-acting insulin divided between meals 1
• As a general rule, 0.2 to 0.4 units/kg of body weight can be used to calculate initial total daily insulin dose 1
• Must be used concomitantly with short-acting insulin 1

Type 2 Diabetes:

• Recommended starting dose for insulin-naïve patients is 10 units once daily 1
• Typically prescribed with metformin and possibly one additional non-insulin agent 3
• Consider initiating insulin therapy when A1C ≥9%, and start immediately when blood glucose ≥300-350 mg/dL or A1C ≥10-12%, especially if symptomatic 3

Dose Titration and Adjustment

• Individualize and titrate dose based on metabolic needs, blood glucose monitoring, and glycemic control goals 1
• The recommended interval between dose increases is 3-4 days 1
• Initial dose can be increased by approximately 2 units every 3 days to reach fasting plasma glucose goal without hypoglycemia 3
• If hypoglycemia occurs, reduce dose by 10-20% 3
• Dose adjustments may be needed with changes in physical activity, meal patterns, renal or hepatic function, or during acute illness 1

Switching from Other Insulin Therapies

Adults with Type 1 or Type 2 Diabetes:

• Start Tresiba at the same unit dose as the total daily long or intermediate-acting insulin unit dose 1

Pediatric Patients (1 Year and Older):

• Start Tresiba at 80% of the total daily long or intermediate-acting insulin unit dose to minimize hypoglycemia risk 1

Special Considerations

• For pediatric patients requiring less than 5 units daily, use the U-100 vial 1
• For adult patients who miss a dose, inject during waking hours upon discovering the missed dose, ensuring at least 8 hours between consecutive injections 1
• For pediatric patients who miss a dose, contact healthcare provider for guidance and monitor blood glucose more frequently 1
• Basal insulin plus a GLP-1 receptor agonist is associated with weight loss and less hypoglycemia but may be more poorly tolerated and expensive than regimens using insulin alone 4
• For elderly patients (>65 years), consider starting at a lower dose of 0.1 units/kg/day to reduce hypoglycemia risk 5

Monitoring and Safety

• Self-monitoring of blood glucose is essential for adjusting insulin therapy 3
• Tresiba should not be administered intravenously or in an insulin infusion pump 1
• Do not dilute or mix Tresiba with any other insulin or solution 1
• Never share Tresiba FlexTouch pens, needles, or insulin syringes between patients 1
• Hypoglycemia is the most common adverse reaction of insulin, including Tresiba 1
• When basal insulin has been titrated to acceptable fasting blood glucose but A1C remains above target, consider adding prandial insulin or a GLP-1 receptor agonist 3

Common Pitfalls to Avoid

• Delaying insulin intensification when oral agents fail to achieve glycemic targets can lead to poor outcomes 3
• Not considering hypoglycemia risk when intensifying insulin therapy, especially in patients on sulfonylureas 3
• Failing to reduce Tresiba dose by 10-20% in patients experiencing hypoglycemic episodes 3
• Using sliding scale insulin alone in patients with type 1 diabetes is not recommended 4